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Patient Resources

Printable Forms

The following files are provided in PDF format. In order to view PDF files on your computer, you must have a PDF reader program installed. If you do not already have such a reader, you can download a free reader at Adobe's website.

 



ADD/ADHD Forms - Authorization for Release of Information

Permission to Communicate with Teachers For students on ADD or ADHD medication. To best care for your child and treat their ADD/ADHD, we request communcation with your child's school personnel.  If... Read More

Athletic Clearance Form

Generally provided by school. This is the WIAA standard form.   Download Form... Read More

Child Health Report

Generally provided by day care. This is the State of Wisconsin standard form.   Download Form... Read More

Forms for New Patients - Print, complete the form(s) and bring along to your first visit

If you are a new patient, please complete this form and bring along to your first appointment.  Download Demographics Form Download Patient History Form and Privacy Notice Download... Read More

General Consent for Admission/Treatment Form

This is the form for General Consent for Admission and Treatment  Download Form for General Consent for Admission and Treatment... Read More

MCHAT Form

Fill out and bring to 18 month and 24 month well checks. Download MCHAT Form... Read More

Permission for Third Party to Seek Treatment

We want our office to be as convenient for you as possible, but we also require documentation to ensure your child's safety and privacy. This form is a guideline; you can modify if needed. We... Read More

Release Medical Records

  Release Previous Medical Records to Lake Country Pediatrics, S.C.  Download release form from ProHealth Care     Release Medical Records From Lake Country Pediatrics... Read More