Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
"The staff at Coastal Pediatrics is the best! We have seen Jessica several times this summer, and she is wonderful! She always goes above and beyond and is careful to answer all of our questions! We could not be happier with the care our kids receive from Coastal Pediatrics!"
Patient Forms
Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Coastal Pediatrics Forms
We’re very excited to have you join the Coastal Pediatrics Family!
Please click on any of the forms below to download and print:
NEW PATIENT PAPERWORK Please print and complete this packet and bring it to our office at your first visit. It needs to be completed for each child in the family. |
ANNUAL UPDATE PAPERWORK Please print and complete this packet and bring it to our office at your annual visit. It needs to be completed for each child in the family. |
VANDERBILT FORMS The Vanderbilt Form is a rating scale that can be completed by parents and teachers to assess performance in children. |
ANXIETY SCREENING FORMS The Screen for Child Anxiety Related Disorders form is a parent or child completed rating scale that assesses how the child is feeling. |
TRANSITION TO ADULT Please print this packet and review it with your child transitioning to adulthood.
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COVID-19 VACCINE FORM Please print and complete this form and bring it with you for your visit. COVID-19 VACCINE CONSENT FORM COVID-19 FACT SHEET COVID-19 VACCINE CONSENT FORM COVID-19 FACT SHEET
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JOIN THE COASTAL PEDIATRICS FAMILY
Lifelong habits are formed early on, so let’s make sure they’re healthy ones! Learn more on how we can help your growing family.
Office Policies
Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)