NEW PATIENT REGISTRATION

Instructions:  Download the following forms and complete prior to your child's first visit.  Additionally, a full copy of your child's medical records, including any/all immunizations, should be received prior to the first visit.  Bring a copy of your child's insurance card and either your SS Card or Driver's Liscense as identification. One set of forms is required for each child. 

• Patient Registration Form
• HIPPA/Consent to Health Information Disclosure
• Alternate Guardian Form
• Patient Health Form
• Financial Policy
• Authorization for Release of Medical Records

ANNUAL RENEWAL FOR ALL PATIENTS

Instructions:  Download the following forms and complete prior to your child's first visit after January 1st of each year.  Remember a copy of your child's insurance card is due at each visit. You will be asked to thoroughly review, verify and sign our computer generated registration renewal form and make any & all necessary updates prior to your child's first visit of the year. It is necessary to complete a full set of forms for each child annually.

• Alternate Guardian Form
• Financial Policy

SCHOOL, SPORTS AND MEDICATION FORMS

Download the appropriate form and complete ALL parental sections PRIOR to your appointment or PRIOR to submission to Middletown Pediatrics for completion of the physician/provider sections.

Kentucky Public School Health Forms include:

• Eye Exam Forms (required for ages 4-6 years old for the first time entry into a Kentucky public school; thereafter all screenings can be done at our office and we will refer to opthomology as necessary)
• Dental Exam Form (new requirement for first time entry into a Kentucky school starting August 2010 for children 5-6 years of age)
• Initial Entry (Headstart-4th Grade) Physical Form
• 6th Grade Entry Physical Form
• Sports Participation & Athletic Form
• Immunization Certificate