Patient Registration Forms

Please print these forms and the forms listed below and bring them with you to your upcoming appointment.

Initial Health Questionnaire for New Patients

Patient and family medical history forms help us provide better care for our patients by allowing us to identify if the patient has a higher risk for a disease, provide early warning signs and treatments to reduce a patients risk for a disease and to help plan lifestyle changes to keep the patient healthy.

Credit Card Authorization Form

A credit card authorization form will be kept on file for all patients in the practice for your convenience.  We accept HSA cards, Visa, Mastercard, American Express and Discover cards.  We also offer payment plans for past due balances.

Notice of Privacy Practices

Crossroads Pediatrics is dedicated to maintaining the privacy of its patients' protected health information under HIPAA.  We are required by law to maintain the confidentiality of this health information. We are also required by law to provide you with this Notice of Privacy Practices which describes our legal duties and your rights.

Our Policies

Please review our office policies to help us provide you with the best experience possible when you visit the Crossroads Pediatrics.

Get a copy of your Medical Records

Use this form to get a copy of your medical records from your child's previous doctors.  We recommend getting a copy of the immunization record, specialist consultation reports, hospital and surgery report and the past 12 months of office visits notes.