Forms

Patient Forms

• New Patient Forms
• Persons Authorized to Seek Treatment Form
• General Consent for Treatment Form
• Patient History Form
• Prescription Refill Request Form

Privacy Information and Forms

• Patient Notice/Privacy Policy
• Acknowledgement of Receipt of Patient Notice / Privacy Policy Form

Medical Records and Patient Information Forms

• HIPAA Authorization Form
• Medical Records Release Form-Sending FROM CMG
• Medical Records Release Form–Sending TO CMG

Medication Dosing Charts

• Acetaminophen
• Ibuprofen
• Diphenhydramine (Benadryl)

Vaccination / Immunization Schedules

• Childhood Schedule (birth – 6 years)
• Adolescent Schedule (7 – 18 years)
• Catch-up Schedule (4 months – 18 years)

Vaccination / Immunization Information Sheets

• Chickenpox (Varicella)
• Diphtheria Tetanus & Pertussis (DTaP)
• Haemophilus Influenzae Type B (Hib)
• Hepatitis A (HepA)
• Hepatitis B (Hep B)
• Human Papillomavirus (HPV)
• Influenza (Flu Shot)
• Influenza (Flu Mist)
• Measles Mumps & Rubella (MMR)
• Meningococcal (MCV4)
• Pneumococcal Congugate (PCV13)
• Polio (IPV)
• Rotavirus (RV)
• Tetanus, Diphtheria & Pertussis (Tdap)

Ages & Stages Information Sheets

• First Month
• 2 – 4 Months
• 4 – 6 Months
• 6 – 9 Months
• 9 – 12 Months
• 1 -2 Years
• Toddler Years
• Adolescent Years

Child Safety Information

• Car Seat Safety Guide

Payment Disclosure Form

• Internet Policy Examples