Forms - Djafari Pediatrics

SWYC FORM

SWYC Forms are filled out at each visit from 2 months to 5 years.

Please select your childs age and complete within 5 days of your childs upcoming appointment. Bring this form to the appointment to save time in the waiting room!

HEALTHeCONNECTIONS

Health e Connections is a tool that allows your PCP, Specialty Providers, and ER Providers access your childs' medical records to achieve the best level of care for your child.

RECORDS RELEASE
(FROM US)

If you are our patient transferring TO another office, please use this form.

INFORMATION SHEET

This form gets filled out yearly, and for every new patient. Save time in the waiting room and bring this completed form with you!

HEALTH HISTORY

This form get filled out yearly, and for every new patient. Save time in the waiting room and bring this completed form with you!

RECORDS RELEASE
(TO US)

If you are a new patient transferring to our office from another office, Please use this form.

HIPPA POLICY

This policy is posted to ensure confidentiality and security of your protected health information.

AUTHORIZATION TO TREAT

Fill out completely and sign for each child, send forms along with the adult accompanying your child.

VANDERBILT ASSESSMENT

Parent and teacher portions are to be completed and provided to your child's doctor prior to their ADHD visit.