We are happy to offer you the option to complete and submit our office forms electronically to reduce wait times during your appointment.
Forms for New Patients (Including Newborns)
(In addition to the forms directly below, please complete the form(s) in the "General Forms for All Patients" specific to patient's age if patient is coming in for a well exam.
- Social Influencers of Health Screening Tool (SIOH)
- Office Policies, Financial Policies & Consent to Treat
- HIPAA Notice of Privacy Practices, & Release of Medical Information
- Vaccine Policy
- Vaccine Policy Acknowledgement
- Initial History Questionnaire
- Patient Information Form / Contact Authorization
- Authorization for Medical Treatment of a Minor
-
Demographic Information
- Insurance Card Upload (Please attach BOTH sides of the insurance card)
- Credit Card on File Authorization
Forms for Newborns Only
- Newborn Welcome Letter
- Birth Record Release (Complete only if baby was born at a hospital other than Hinsdale Hospital.)
General Forms for All Patients
- Social Influencers of Health Screening Tool (SIOH)
- Vaccines for Children (VFC Program) (Please complete this form for EVERY visit ONLY if the patient has Meridian or All Kids Insurance.)
Exam for 2-month-old:
Exam for 9-month-old:
Exam for 12-month-old:
Exam for 15-month-old:
Exam for 18-month-old:
Exam for 2-year-old:
- Childhood Lead Risk Questionnaire
- Lead Zip Code List
- Tuberculosis Risk Assessment Questionnaire
- M-CHAT (Modified Checklist for Autism in Toddlers)
- Vision Screening Information
- Vision Screening Authorization
Exam for 2 1/2- year- old (30-month-old)
Exam for 3, 4, 5 and 6-year old:
- Childhood Lead Risk Questionnaire
- Lead Zip Code List
- Tuberculosis Risk Assessment Questionnaire
- Vision Screening Information (3-year-olds only)
- Vision Screening Authorization (3-year-olds only)
- Hearing Screening Authorization (4-year-olds only)
Exam for Kindergarteners:
- Childhood Lead Risk Questionnaire
- Lead Zip Code List
- Tuberculosis Risk Assessment Questionnaire
- Updated History Questionnaire
Exam for 7 through 9- year-old:
Exam for 6th Grade, the 9th Grade/HS Freshman:
Exam for 10 years and over:
Patients 18 years old and over:
-
HIPAA Notice of Privacy Practices, & Release of Medical Information for Adult Patients
- Office Policies, Financial Policies & Consent to Treat
- Contact Form
-
Demographic Information
- Vaccine Policy Acknowledgement
Information for College Students about Meningococcal B and Meningococcal Conjugate-As of 2018, some states, including Indiana,* require all students attending residential campuses at colleges to be immunized against Meningococcal disease by receiving the following vaccines:
- Meningococcal Conjugate-one dose on or after 16th birthday
- Meningococcal B (Brand name-Trumenba)-2 doses 6 months apart or thereafter for students 10-25 years old
*Check with your school before attending for their requirements.
*Check with your school before attending for their requirements.
Beyfortus (RSV Shot) Agreement Form:
Leaving the Practice: This form requires a non-electronic signature.
Releasing records FROM another office TO DuPage Pediatrics : This form requires a non-electronic signature.
Authorization to Keep a Credit/Debit/HSA Card on File:
Request to Set Up a Payment Plan:
Upload Your Insurance Card:
- Insurance Card Upload (Please attach BOTH sides of the insurance card)
Authorization to have someone other than a parent or legal guardian bring in a child for care:
HIPAA Notice of Privacy Practices:
- Click here to view the HIPAA notice for DuPage Pediatrics.