Forms

Completing forms before you visit

To help us provide excellent care and bill your insurance company for services, please complete the forms below. If you are visiting the office for a Well Child Check, please also fill out the age-appropriate form. To complete forms:

  • Fill out the forms using Adobe Reader. If you need to download the software, click here to access the free Adobe Reader.
  • Email completed forms as attachments to blufftonpediatrics@gmail.com. We will put the information in your child's Electronic Medical Record (EMR).

If you have any questions, please contact Beth through the patient portal.

New Patient Forms

Well Child Check

Each time you bring your child to for a WCC, complete the form below that most closely matches your child's age.

Infancy

Middle Childhood

Early Childhood

Adolescence

The American Academy of Pediatrics recommends the above schedule for wellness visits. For more information, view the AAPs Periodicity Schedule for Well Child Checks, which provided detailed lists of recommended measurements, examinations, screenings, procedures, and assessments.