Forms


Save time by downloading these forms at home.  


When completed, please send them to:
medicalrecords@camelbackpeds.com
Patient Registration Packet 

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

Telephone/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.)

Record Release Form

Consent to Release Information form (for patient's 18 or older)

Patient Behavioral Health Surveys

MChat
Vanderbilt Parent's
Vanderbilt Teacher's
PHQ-9 Modified for Teens
PHQ-9 Adult
SCARED Anxiety Screen - child to complete
SCARED Anxiety Screen - parents to complete
GAD-7 Anxiety Screen 
Attention Deficit Disorder Initial Intake Questionaire
 

For the most up-to-date information on our accepted private health insurance plans

contact our clinic directly at 602-840-3120