8-12 Year Forms

8 to 12-Year Forms

The CMS (Centers for Medicare & Medicaid Services) and the American Academy of Pediatrics have respectively required and recommended all the patient forms. All insurance companies are requiring us to have these completed for reimbursement. We apologize for any inconvenience this causes. We apologize for any duplicate fields in these forms.

HIPAA Consent to Treat (Select Appropriate Clinic)

For which clinic is this form?
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 Update


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



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


Healthy Habits (Child)

Enter a confirmation email address.


1. My child eats this many servings of veggies a day (a serving is about the size of your fist)
2. My child eats this many servings of fruits a day (a serving is about the size of your fist)
3. My child eats out
4. My child is active
5. My child has sweet drinks soda, sweet tea, 100% fruit juice, sports drinks, other fruit drinks)
6. My child watches television, plays video games, spends (non-school related) time on the computer, table, or cell phone
7. Most nights, my child sleeps
8. If you could work on one healthy habit, which would it be?




1. Is this child adopted? *
2. Are the medical records available or medical history known for parents or grandparents? *
3. Has either parent or any grandparents experience any of the following? Check all that apply.
4. Is this child overweight? *
5. If your child has risk factors for high cholesterol or early heart disease, are you interested in screening labs? *

Special Note

FAQ Sheet: Lipid Panels

The AAP recommends lipid screening beginning at age 8 years for the following populations:

*Obese children: defined as a BMI greater than the 95% for age (E66.9)

*Children whose parents or grandparents have had a heart attack, stroke, or blocked arteries younger than 65 in women and 55 in men (Z82.41, Z82.49)

*Children who have a parent or grandparent with a total cholesterol of 240 mg/dl or higher (Z83.42)

*Children whose family history is unknown. (Z84.89)

(Source: healthychildren.org 8/20/2020)

We at Storybook Pediatrics also recommend this screening.

We do recommend that you check with your insurance company prior to this lab draw to ensure that they will cover these labs.
The codes for the diagnoses are listed above. You can provide your insurance company with the appropriate codes

If your child is obese, we recommend the following labs:

Lipid panel

Hemoglobin A1C


If there is relevant family history or family history is unknown, we recommend the following:

Lipid panel

Alternatively, if you wish to do so, we can send the labs as self pay. The self pay prices are listed below for Lab Corp. Our phlebotomist can draw these labs and send them to the lab.

Lipid Panel: $102.90

Hemoglobin A1C: $69.30

ALT/AST: $77.70