Appointment Request 
Patient Portal 
Pay My Bill 
Our patient forms are here for you should you ever need them. However, we have invested in new technology to improve our check-in process, saving both time and paper. Instead of being given a clipboard with several paper forms to complete, you will now have the ability to complete registration electronically through Phreesia.
General Forms
Medical Information Forms
- Patient Medical History and Registration Form
- Child Family History
- Tuberculosis Screening Questionnaire
- Sports Physical Form
HIPAA Forms
- HIPAA Notice of Privacy
- Privacy Notice and Consent to Treat Acknowledgment and Financial Policy Agreement
- Parent Authorization Form
- Medical Record Release
Developmental Screening Forms
Well – Visit Forms
- HOSPITAL FOLLOW UP VISIT FORM
- Lactation Initial
- Lactation Follow-Up
- 2 WEEK VISIT FORM
- 1 MONTH VISIT FORM
- 2 MONTH VISIT FORM
- 4 MONTH VISIT FORM
- 6 MONTH VISIT FORM
- 9 MONTH VISIT FORM
- 12 MONTH VISIT FORM
- 15 MONTH VISIT FORM
- 18 MONTH VISIT FORM
- 2 YEAR VISIT FORM
- 2 1/2 YEAR VISIT FORM
- 3 YEAR VISIT FORM
- 4 YEAR VISIT FORM
- 5 YEAR VISIT FORM
- 6-11 YEAR VISIT FORM
- 12-15 YEAR VISIT FORM
- 16-17 YEAR VISIT FORM
- 18 YEARS AND OLDER
Clinical Information Handouts
Depression & Anxiety Forms
- PHQ-9 (for adolescents 12 years old & up)
- Anxiety Screen- SCARED (parent completion)
- Anxiety Screen- SCARED (child completion)
- Postpartum Depression Screen
ADHD Forms and Questionnaires
Letter/ Forms Completion
We will gladly fill out the required forms for your child at his or her well checkup at no charge. However, if you need any forms/ letter completed outside of your scheduled well-child appointment, there will be a fee per child. The Carithers Pediatric Group reserves the right to modify these charges from time to time at our discretion. If a type of form presented for completion is not included in this list, we reserve the right to apply a fee that we deem appropriate.
Daycare/ School forms, WIC Forms: $5.00
College forms, Sports/Camp forms, and Overseas/Travel forms: $10.00
FMLA/ Disability forms: $20.00