Intake Form – Child

This form is for child patients (6 months – 18 years). For adult patient, please click here.

Please complete the form prior to your child’s appointment to help ensure the visit is as smooth as possible. If you have any concerns about a question in the form please leave it blank and we will any address it at the time of the visit.

All information provided is kept secure and HIPAA compliant until it can be entered into your child’s electronic medical record ( Patient Fusion ). After recording the information all forms are deleted and no personal information is used for any purpose other than improving your health.