Secure Online Forms

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
  
• RSV Prophylaxis Screening (Complete only if child is 2 years old or younger)
• 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.)
• PKU Results Request (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:

• Edinburgh Postnatal Depression Scale (EPDS)
  

Exam for 9-month-old:

• Infant Development Chart

Exam for 12-month-old:

• Childhood Lead Risk Questionnaire
• Lead Zip Code List
• Tuberculosis Risk Assessment Questionnaire

Exam for 15-month-old:

• Vision Screening Information
• Vision Screening Authorization

Exam for 18-month-old:

• M-CHAT (Modified Checklist for Autism in Toddlers)

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) 

• ASQ-3

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:

• Tuberculosis Risk Assessment Questionnaire

Exam for 6th Grade, the 9th Grade/HS Freshman:

• Tuberculosis Risk Assessment Questionnaire
• Physical Activity Form
• Updated History Questionnaire

Exam for 10 years and over:

• Tuberculosis Risk Assessment Questionnaire
• Physical Activity Form

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.

Leaving the Practice:

• Request to Transfer Medical Records
  

Releasing records FROM another office TO DuPage Pediatrics :

• Release of Incoming Records

Authorization to Keep a Credit/Debit/HSA Card on File:

• Credit Card on File Authorization

Request to Set Up a Payment Plan:

• Payment Plan Form

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:

• Authorization for Medical Treatment of a Minor
  

HIPAA Notice of Privacy Practices:

• Click here to view the HIPAA notice for DuPage Pediatrics.

Vaccine Policy Acknowledgement:

• Vaccine Policy
• Vaccine Policy Acknowledgement