FORMS

Forms for New Patients

The office will need all completed forms and medical records request form prior to the first appointment being made.

Please click the link below to complete our new patient forms online via pdfFiller. Please complete the AAKP New Patient Packet for the first new child joining our practice and then complete the Additional Patient Packet for each additional child joining the practice. If your child is a newborn with siblings in the practice already, please complete the New Patient Packet. Once completed, pdfFiller will alert us to any paperwork that is completed; it will also allow you to download a copy of the forms to keep for your records. New Patient paperwork is held by AAKP for 60 days, if no appointment is made within 60 days of receipt of paperwork the paperwork is shredded.  Please note that we run every Self Pay patient through our Medicaid eligibility website; any Self Pay patient with active Medicaid will not be accepted into the practice.

AAKP New Patient Packet
Additional Patient Packet

Forms for New Mothers
Prenatal Visit Form (complete form prior to birth of child for prenatal visit).

Release and Authorization Forms
Non Parental Consent to Treatment Use this form to authorize treatment if someone other than a parent or guardian is bringing in a child for a visit.

Medical Records Request Form Use this form to request records to be sent to another physician or for another physician to send records to AAKP.

Medical Disclosure Form Use this form to grant AAKP authorization to disclose medical information to outside agencies(Adoption agencies or schools)