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. One of our Pediatricians is always on-call and is available for urgent conditions after-hours. Please page the doctor on call at (810) 986 5058. Your call will be answered promptly.