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Patient Forms

Download and complete the necessary forms for your visit. All forms are available in PDF format and should be printed, completed, and brought to your appointment.

New Patient Forms

NEW PATIENT REGISTRATION PACKET

Click on the form to download forms for your upcoming visit. Please print and fax or mail to us before your first visit.

HIPAA NOTICE OF PRIVACY PRACTICES

CONTACT INFORMATION

Tele-medicine Form

TELE-MED INSTRUCTIONS

Well Forms

Please click on the links below to download forms. Please print and bring to your next WELL CHILD VISIT.

INFANT 1-11 MONTHS

TODDLER 1-4 YEARS

CHILD 5-10 YEARS

TEENS 11 AND UP

Developmental Forms

Click on the links below to download forms for your upcoming visit. Please Print and fax or mail to us so we may schedule an appointment. If this is your first visit, please also complete the New Patient Forms above.

ADHD RELATED FORMS

Use this questionnaire for all attention related difficulties.

DEVELOPMENTAL FORMS

Use this questionnaire for all developmental issues other than attention problems.

SNAP-IV QUESTIONNAIRE

This is useful for following up with teachers related to attention issues.

Office Forms

Click on the link below to download or view forms. Please Print and fax or mail to us.

RECORD RELEASE FROM THOUSAND OAKS PEDIATRICS

There is a charge for this service.

PERMISSION TO AUTHORIZE CARE

Use this form to give other caretakers permission to authorize treatment of your child.

CONSENT TO RECEIVE EMAILS AND TEXT MESSAGES

FINANCIAL POLICY

PEDIATRIC HISTORY FORM

NO SHOW/CANCELLATION POLICY

PATIENT DEMOGRAPHICS

ANNUAL ADMINISTRATION FEE

CAIR IMMUNIZATION REGISTRY FORM

Vaccines

Click on the links below to download or view information:

Immunization for Babies

This is a good summary for the first two years.

Immunization for Children and Adolescents

This has all the basic vaccines we recommend from birth through adolescence.

VACCINE STATEMENTS in English and other languages

These are the official forms we are required to give you at each visit.

CDC Detailed Vaccine Schedule 0-18 years