Patient Forms

New Patient Forms

New Patient Packet: Please complete these forms and bring them to your child’s first appointment

Release of Information Request to LaTouche Pediatrics: Please complete this form and submit it to your child’s previous provider(s) in order for us to receive your child’s medical records

Prenatal Form

Prenatal History Form: Please complete this form and bring to your prenatal appointment

Existing Patient Forms

Consent and Authorization for Treatment of a Minor: Please complete this form if you would like to authorize other adults to bring your child to appointments, make requests, or pick up prescriptions

Consent and Authorization for Patient Over 18: Please complete this form if you are a patient, 18 years old or older, and would like to authorize your parent(s) to make requests, pick up prescriptions, have patient portal access, or have access to your medical records

ADD/ADHD

ADD/ADHD Parent Questionnaire: Please complete this form and bring it your child’s ADD/ADHD appointment

Vanderbilt Parent Form: Please complete this form and bring to your child’s ADD/ADHD appointment

Vanderbilt Teacher Form: Please have your child’s teacher complete this form for you to bring to your child’s ADD/ADHD appointment

Behavioral Health 1st Evaluation Forms

PCL5_Standard_form: Please complete this form and bring it your child’s Behavioral Health 1st Evaluation Appointment with Andrea Swanson

Alaska Screening Tool : Please complete this form and bring it your child’s Behavioral Health 1st Evaluation Appointment With Andrea Swanson

Additional Behavioral Health Forms

SCARED – Parent version: This form is to be completed by the parent for the patient, if instructed by a provider.

SCARED – Patient Version: This form is to be completed by the patient, if instructed by the provider.

PHQ-9: This form is to be completed by the patient if instructed by the provider.