Forms need downloaded, printed, and signed. Signatures must be actual and not electronically generated.

Note: Some of the following forms are in PDF format. If you have problems with viewing them, please click below to download Adobe Acrobat (PDF) Reader.

Influenza Vaccine Consent Forms (New)

• (New) Please fill out and bring this form to the office when getting your flu shot for 2010/2011

Transfer Forms

Transferring from CHS

• Request form for Medical Records to be transferred to Village Pediatrics
  • Please fax completed form to CHS at 203-221-1736

Transferring from any other practice

• Request form for Medical Records to be transferred to Village Pediatrics

New Patient Forms

Please print, fill out, sign, and bring to first visit (All Patients including former CHS patients!)

• Medical History Questionaire
• New Patient Registration Form
• Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy and Consent for Minors to Seek Medical Care Form
• (New) Added Benefits Plan form
• Financial Policy Form

Required State Health Forms

• State of CT Department of Education - Health Assessment Record form (This form MUST be printed on BLUE paper!)
• State of CT - Early Childhood Health Assessment Record form

Assessment Tools for Parents

• SNAP - Teacher and Parent Rating Scale  http://www.adhd.net/snap-iv-form.pdf
• MCHAT - Modified Checklist for Autism in Toddlers  http://www2.gsu.edu/~wwwpsy/faculty/M-CHAT.pdf
• PSC - Pediatric Symptoms Checklist form  http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf
• New Mother Post-Partum Depression Evaluation

Teen Screening

• 16-22 years
• 12-15 years
• Parent Questionnaire

Exercise & Nutrition Assessment

• Personal Profile of Exercise and Nutrition (Fill out online and print)