Forms & Policies

Required Patient Forms
To expedite your first appointment, please arrive a few minutes early to complete registration forms so that we have all the necessary information to treat your child. You may also download and print the forms from this website, fill them out ahead of time, and bring them with you to the first appointment.

Patient Registration Form:  All patients need to fill out this form. Please fill it out as completely as possible, as all of this information is important for us.

Medical and Family History: Needs to be filled out for all new patients. Please visit the CHADIS website and choose "First Time Visit to Tamalpais Pediatrics" as a visit type.  You will need to enter the invitation code "4154610440".  Please visit our Pre-visit CHADIS Page for more information on this service.  Please fill these out as completely as possible, to help us learn about your child’s past medical history and elements of your family history that may affect your child’s health.

Release of Medical Records: This form allows us to get records from your previous doctors. Please fill out and return this form to the office staff prior to your appointment to ensure that your records are received in a timely manner. We need to have received your previous records before scheduling an annual check up appointment. You can send this to your previous pediatrician yourself or bring it to the visit and we will fax it for you. This form is not necessary for new babies.

Financial Policy: Is for you to read and keep. Please read these and ask us if you have any questions. This is our office policy related to how we bill you and your insurance for services that are provided.

Notice of Privacy Practices: Is for you to read and keep. Please read these and ask us if you have any questions. These are our office policies related to the privacy of your child’s medical records.

Acknowledgement of Receipt of Privacy Practices: Shows that you received the Notice of Privacy Practices. All patients need to sign this form and turn it in to us.

Acknowledgement of Receipt of Privacy Practices (for patients over age 18): This form is for young adults over the age of 18. This shows that you received the Notice of Privacy Practices. All patients need to sign this form and turn it in to us.
 
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Teen Visit
Travel Consultation Visit
Nutritionist Visit
Our MMR Policy
Policies