12-Month Forms

HIPAA Form

HIPAA Consent to Treat (Select Appropriate Clinic)

For which clinic is this form?
(MM/DD/YYYY)
I (we), the legal quardians of the above named children do hereby give my(our) consent for the persons listed below to obtain medical care for my (our) children at Storybook Pediatrics. I (we) understand that by giving persons permission to take my child/children to Storybook Pediatrics for medical care, I am also giving Storybook Pediatrics permission to disclose my child's (children's) protected health information to any of the persons on this list. I also understand that by giving these persons permision to take my child (children) to Storybook Pediatrics for medical care that I am also giving these persons my permission to make medical care decisions for my child (children) during those visits. Parent or Legal Guardian Signature: *
Interim History

Interim History Update

(MM/DD/YYYY)

Current Contact Information

Mom's Relationship
Email verification
Email verification
Father's Relationship
Email verification
Email verification
Email verification

Interim Medical History

Current Prescription Oral Medications

Current Prescription Topical Medications (creams, etc.)

Current Prescription Inhaled Medications

Current Over-the-Counter Medications

Allergies

Environmental

Primary water source (for children under six)
Does this child (if under age three) live in or frequently visit a house constructed before 1978?

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