FOR SCHEDULED PATIENT VISITS ONLY* (forms work best on laptop or tablet)
Please complete appropriate forms the SAME DAY as (no sooner than 24 hours before) your scheduled appointment in order to give us the most current information. Depending on the concern or situation, you may need to complete forms from multiple sections.
Please be advised that by providing this form for you to contact our office(s), we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into this portal. Our office will follow up with you within 24 to 48 business hours. Please note: We may not see submitted forms for 24 hours depending on when the forms were completed. For any safety concerns, thoughts of self-harm or suicide, or severe medical symptoms please call 911 for medical emergencies or text “help” to 741-741 or call the National Suicide Hotline at 1-800-273-8255, https://
*Not intended for use by the general public but only for patients with scheduled appointments.
PARENT INPUT (welcome and encouraged for patients of all ages)
For all new visits, annual exams, mental health/nutrition health assessments and updates.
NEW PATIENT APPOINTMENTS & ANNUAL WELLNESS (for NEW or ESTABLISHED patients)
Complete both Part 1) Medical History & Part 2) Patient Survey
- Part 1 (new patients and updated by established patients annually)
- Part 2 (new patients and updated by established patients annually, choose by age/development as appropriate)
Provide details of current acute illness complaints.
OTHER MEDICAL PROBLEM VISITS
Provide details of non-acute, recurrent, or chronic conditions.
- NEW CONCERNS
- Acne Evaluation (under construction)
- History (under construction)
- Follow Up (under construction)
Complete Mental Health History for new patient mental health evaluation or new concern in established patient. Complete Patient Symptom Report for both new and/or follow up appointments for mental health concerns.
- Mental Health History (by PARENT or ADULT PATIENT, new evaluation)
- Patient Mental Health Report (by PATIENT for new and follow up evaluations)
- Mood Disorders Screening Questionnaire (by instruction only)
Add to Mental Health forms if concerns about nutrition patterns, body image, or eating disorders.
- Nutrition History (by PARENT or ADULT PATIENT for new evaluations)
- Nutrition – PATIENT report (by PATIENT for new and follow up evalations)
- Nutrition – PARENT Input (by PARENT for new and follow up evaluations)
FOR OFFICE USE ONLY / BY INSTRUCTION ONLY