Forms

Consent to Disclose PHI for 18 yr old pts

(for patient's 18 or older)

Patient Registration Packet

Completed forms can be sent ahead of scheduled appointment to medicalrecords@camelbackpeds.com

Telemedicine Consent Form

(NOTE: To sign digitally, you must open the document in a PDF application, complete, sign and email back to us. Optionally, you can print, complete, scan and return via email.)

Medical Records Release - Incoming Records

Consent by Proxy for Non-Urgent Care

Medical Records Release Form

Medical Records Release Form - Outgoing Records

Outgoing Medical Records Release

Request to send records elsewhere

Incoming Medical Records Release

Request to send records to Camelback Pediatrics

ADHD Treatment Contract

ADHD Parent Initial Form

ADHD Parent Follow-Up Form

ADHD Teacher Initial Form

ADHD Teacher Follow-Up Form

Anxiety Treatment Contract

GAD-7

SCARED Anxiety Screen (child to fill out)

SCARED Anxiety Screen (parent to fill out)

Depression Treatment Contract

MCHAT

PHQ-9