Patient Forms

To expedite our patient registration process and save you time at the office, please download and print all of the applicable forms below, and fill them out before you come in for your visit.

New Patients

Registration Form

If you are a new patient, please complete this form and bring it with you to your first appointment.

Initial History Questionnaire

Printing and filling out this form at home will save you additional time in our office before your visit.

Records Release TO Brighton Pediatrics

Please complete this form so that your child’s medical records can be released TO Brighton Pediatrics from your previous medical provider/clinic.

Privacy Notice

If you are a new patient, we will ask you to read and sign a Privacy Notice. To save you time in the office, please read and sign this document. Bring only the signed last page with you to your appointment.

Permission to Treat

Please complete this form to notify us as to the individuals who may bring your child to the office for treatment. Without this form, we will be unable able to deliver medical service to your child if he or she is accompanied by someone other than the listed parent(s)/legal guardian.

Established Patients

Change of Insurance or Address

Please complete this form if you have a change of address or change of insurance and bring it with you to your next appointment.

Screening Questionnaire for Child & Teen Immunizations

Please bring this completed form to any “vaccine-only” visit.

Records Release FROM Brighton Pediatric Center

Please fill out this form to have your child’s medical records released FROM Brighton Pediatric Center to a different doctor/ Clinic.

Privacy Notice

If you have not read and signed a Privacy Notice for your child(ren), please read and sign this document. Bring only the signed last page with you to your appointment.

Physicals

Schedule of Well Child Visits

This schedule is recommended by American Academy of Pediatrics. The Doctor will evaluate your child’s general health, growth and development. In these visits, the doctor will give your child important medical services, such as: Health exam, Vision, Hearing, lab tests, Shots, referral…etc.

Pre-Participation Physical Evaluation

Please have your child complete this form prior to his or her scheduled sports physical.

Adolescent Patient Information Form

When our pediatricians see adolescent patients, we request the adolescent complete a short confidential questionnaire. Please print this form and have your child complete it before his or her appointment. Your child can give the form directly to the pediatrician to protect his or her feeling of confidentiality. If you have any questions regarding this form, please do not hesitate to contact our office.

School Forms

Sport Participation

If your teen will participate in any High school athletic activity, Please fill out the applicable blanks and bring this form with you.

Michigan Health Appraisal

This is a universal form for any school registration in Michigan

Authorization for administering Medication in Brighton Schools

Complete this form if your child may need to take any medication in school (Inhaler, Pain meds…)

Authorization for administering Medication in Howell Schools

Complete this form if your child may need to take any medication in school (Inhaler, Pain meds…)

Authorization for administering Medication in Any School

Complete this form if your child may need to take any medication in school (Inhaler, Pain meds…)

Asthma Education

Asthma Questionnaire for children 4-11 yr old

If your teen will participate in any High school athletic activity, Please fill out the applicable blanks and bring this form with you.

Asthma Questionnaire for Adolescents 12 yr and older

This is a universal form for any school registration in Michigan

ADD / ADHD

Initial Evaluation: ADHD Parent Assessment

Parents may print and complete this form prior to their child’s appointment for evaluation of ADD/ADHD. Please bring both completed forms to your appointment.

Initial Evaluation: ADHD Teacher Assessment

Parents may print and have your child’s teacher complete this form prior to your child’s appointment for evaluation of ADHD. Please bring both completed forms to your appointment

ADHD Parent Follow Up Form

Complete these forms only if your pediatrician requests them for a follow up visit.

ADHD Teacher Follow Up Form

Complete these forms only if your pediatrician requests them for a follow up visit

ADAPT: Accommodations for Students with ADHD

Examples of accommodations which teachers can make to adapt to the needs of students with ADD/ ADHD.

Patient Centered Medical Home

Patient-Provider Partnership

Patient Centered Medical Home is a health care delivery model which creates a trusting partnership between you, your primary care doctor, and your family. The only way we can meet this goal is by working together.

What to do when the office is closed?

Unless it’s an emergency, call your doctor before going to the emergency room. This document provides some guidelines on when to go to the ER and when to call your physician.