We have organized all of the forms you will need for your child’s health visits by age. Please click on the age group for details on which forms you should fill out prior to your visit and bring all forms filled out to your appointment along with medication list and/or inhalers.

Birth or New Patients:

  1. Patient Registration Form (PDF)
  2. Private Health Information Form (PHI) (PDF)
  3. HIPAA (PDF)
  4. Billing & Financial Policy (PDF)

2 months to 15 months:

  1. Registration (if new address or insurance) (PDF)
  2. PHI Authorization Form (if there are any changes) (PDF)

18 month to 2 years:

  1. Registration (if new address or insurance) (PDF)
  2. PHI Authorization Form (if there are any changes) (PDF)

3 years to 12 years:

  1. PSC-17 Girl (PDF)
  2. PSC-17 Boy (PDF)
  3. Registration (Required annually or with new address or insurance) (PDF)
  4. PHI Authorization Form (if there are any changes) (PDF)

13 years to 17 years:

  1. PHQ-9 (PDF)
  2. Registration (Required annually or with new address or insurance) (PDF)
  3. PHI Authorization Form (if there are any changes) (PDF)

18 years & up:

  1. PHQ-9 18+ (PDF)
  2. HIPAA (PDF)
  3. Registration (patient should fill out) (PDF)

Commonly Used PMA forms & School Forms

Below please find a list of commonly school and Pediatric Medical Associates forms.

School Forms

Please complete page 1 and bring with you to your appointment

  1. Day Care Health Assessment Form (PDF) – Also known as the Yellow form
  2. School Health Assessment Form 5 years (PDF) – Also known as the Blue form

PMA Forms

  1. New Patient Registration Form 2017 (PDF)
  2. Notice of Privacy Practices (PDF)
  3. HIPAA Acknowledgement (PDF)
  4. Billing and Financial Policy (PDF)
  5. Medical Records Instructional Letter (PDF)
  6. PHI Authorization Form (PDF)
  7. Authorization for Release of Patient Records (PDF)

Get In Touch

For non-emergencies please fill out the form below to contact our New Haven or Cheshire offices