Patient Forms

 Admin–1-NEW PATIENT REGISTRATION Revised 4-20-18 Admin–2-NEW PATIENT REGISTRATION Rev’d 7-6-15 Con’d –– fill this out if you’ve never made an appointment with us before, or if this is your first visit in 2016 and/or haven’t filled one out before.  It contains important office policy information as well as a HIPAA acknowledgement that needs to be signed. HIPPA — HIPAA = Health Insurance Portability and Accountability Act — our official HIPAA policy.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION — Mail or fax this form to your previous doctor so they can release your medical records to Ptarmigan Pediatrics. Or fill it out, sign it, leave it with us and we’ll fax it to them for you. Admin–2-PARENTAL CONSENT FOR MEDICAL TREATMENT Revised 7-6 -15 (Guardianship form)  — If anyone other than the parent / legal guardian is going to bring your child to our office, we must have this form or similar authorization on file.  If you are a legal guardian and not the parent, please volunteer your paperwork to us so we can avoid any potential confusion. Consent for Anesthesia / Procedure (Circumcision) — This form will be completed together by the parents and doctor prior to this procedure. Lumbar Puncture Consent — This form will be completed together by the parents and doctor prior to this procedure.

Acute — Sudden-onset illnesses not specifically covered below, including fevers without other symptoms, Routine/Follow-up, Sore throat, and Cough/Cold/URI ADHD — For follow-up visits only. Use the ADHD Packet below for new evaluations. Asthma Ear or Eye Pain GI — Vomiting/Diarrhea, and Abdominal Pain/Constipation Urinary Rash Warts Dental Pre-Op

Prenatal visits can be scheduled for any of our providers, and the following providers all have privileges at Mat-Su Regional Medical Center and can also attend the delivery at the hospital as necessary: Dr. Beaubien, Dr. Westphal, Dr. Tomasoski, and Dr. Smith. Drs. Peterson, Hess, Beaubien, and Smith all do circumcisions as well. Note that most insurance companies draw a distinction between “sick office visits” and “well child visits,” and often have different benefits for each.  Well Child Visits are a form of preventative medicine, meant to catch any potential problems in a child’s physical or developmental health. These visits also give parents an opportunity to ask any questions regarding physical or developmental changes they have noted in their child. Each exam is tailored to the individual child and to the child’s age, and may include necessary immunizations, vision, hearing, and developmental screenings. If your child requires significant medical intervention or you request noteworthy changes to management of existing chronic problems during this appointment, this may go above and beyond a preventative exam and may be coded and billed accordingly with your insurance. If your insurance carrier provides different benefits for well child and sick office visits, your financial responsibility may also change. Prenatal Questionnaire — If you would like one of our doctors to be your newborn’s pediatrician, attend the delivery if necessary, and take care of your newborn at Mat-Su Regional Medical Center after delivery, then they’re happy to do so. We will gladly make a complimentary appointment to meet with you in our clinic in preparation for that day. This prenatal questionnaire will help us get to know each other better. Feel free to print this out and bring it with you to your prenatal visit. Call us a few weeks before your due date to schedule this appointment. Well child visits for patients older than 2 weeks will involve the most paperwork. If you have a chance to print these out ahead of time, you will save significant time in the waiting room and will help our office run more efficiently. The Well Child Forms address your child’s health history, and the“ASQ” — Ages and Stages Questionnaires are age-based screening tools that address your child’s development.  You can access the ASQ portal and submit the ASQ ONLINE HERE. Our recommended well child exam schedule is highlighted below; if your appointment falls outside those ranges, please feel free to mix and match well child forms to most closely match your child’s age on the appointment date.  The ASQ Online submission form will choose the most appropriate questionnaire based on your child’s current age. Note that vaccines are typically given at 2, 4, 6, 12, 15, and 18 months, as well as between 4-6 years and between 11-12 years. Newborn:   Newborn Questionnaire & EPDS form. NOTE:  Parents must bring their child’s 2nd newborn screen card to their baby’s newborn checkup!  The card was provided by the hospital at discharge. Parents are responsible for the security of that card and will be charged by the hospital for replacement cards. FRIENDLY REMINDER: It is your responsibility to get your newborn added to your insurance policy within 30 days of birth, after which your charges will become your sole responsibility. See our financial policy page for more information! 2 Week:  2 Week Well Baby & EPDS form 2 Month:  2 Month Well Baby & appropriate ASQ (Online) & EPDS form (Vaccines typically given) 4 Month:  4 Month Well Baby & appropriate ASQ (Online) & EPDS form (Vaccines typically given) 6 Month:  6 Month Well Baby & appropriate ASQ (Online)  & EPDS form (Vaccines typically given) 8 Month:  Choose closest Well Child above or below & appropriate ASQ (Online) (Vaccines typically given) 9 Month:  9 Month Well Baby & appropriate ASQ (Online) (Vaccines typically given) 10 Month:  Choose closest Well Child above or below & appropriate ASQ (Online)  12 Month:  12 Month Well Child (1 yr) & appropriate ASQ (Online)  (Vaccines typically given) 14 Month:  Choose closest Well Child above or below & appropriate ASQ (Online) 15 Month:  15 Month Well Child & 14 Month ASQ  OR  appropriate ASQ (Online) (Vaccines typically given)
16 Month:  Choose closest Well Child above or below & appropriate ASQ (Online) 18 Month:  18 Month Well Child  & appropriate ASQ (Online) & M-CHAT form (Vaccines typically given)
20 Month:  18 Month Well Child & appropriate ASQ (Online) & M-CHAT form
22 Month:   24 Month Well Child (2 yr) & appropriate ASQ (Online) & M-CHAT form
24 Month:  24 Month Well Child (2 yr) & appropriate ASQ (Online) & M-CHAT form
27 Month:  Choose closest Well Child above or below & appropriate ASQ (Online) & M-CHAT form
30 Month:  30 Month Well Child & appropriate ASQ (Online) & M-CHAT form
33 Month:  36 Month Well Child (3 yr) & appropriate ASQ (Online)  & M-CHAT form
36 Month:  36 Month Well Child (3 yr) & appropriate ASQ (Online) 
42 Month:  Choose closest Well Child above or below & appropriate ASQ (Online) 
48 Month:  48 Month Well Child (4 yr) & appropriate ASQ (Online)  (Vaccines may be given)
54 Month:  Choose closest Well Child above or below & appropriate ASQ (Online) (Vaccines may be given)
60 Month:  60 Month Well Child (5 yr) & appropriate ASQ (Online) (Vaccines may be given)
6 – 12 year old:  6-12 Year Old Well Child (Vaccines may be given)
Teen:  Teen Well Child (13 – 17 yrs) (Vaccines may be given)

For an initial evaluation to assess possible Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder, download the first four forms. The first two forms should be completed by the parent. Give the second two forms to the child’s teacher and instruct the teacher to return them to you when they’re finished.  Bring them to our clinic as soon as you have them completed.  Once the papers are in hand, we can set up the initial appointment. Initial Evaluation:  ADD/ADHD Subjective Assessment  — Parent Form 1 of 4 These forms need to be completed and brought in before the initial appointment can be scheduled. Initial Evaluation:  ADD/ADHD Vanderbilt Form — Parent Form 2 of 4 These forms need to be completed and brought in before the initial appointment can be scheduled. Initial Evaluation:  ADD/ADHD Subjective Assessment — Teacher Form 3 of 4 These forms need to be completed and brought in before the initial appointment can be scheduled. Initial Evaluation:  ADD/ADHD Vanderbilt Form — Teacher Form 4 of 4 These forms need to be completed and brought in before the initial appointment can be scheduled. Follow-up Evaluation:  ADD/ADHD Follow-up Form — For patients who have been diagnosed with ADD/ADHD. M-CHAT (Modified Checklist for Autism in Toddlers) A screening tool designed to help doctors identify children aged 18 – 36 months who may be at risk for developmental delays. EPDS (Edinburgh Postnatal Depression Scale) A screening tool designed to help doctors identify mothers at risk for post partum depression. Mothers coming in for well-baby checks for their children up to age 6 months will be asked to complete this form on each visit. You may save time by printing and completing it just prior to your appointment.

Matanuska-Susitna School District Physical Exam Form — for school entry; it is not a sports activity form Sports/Activity Form Allergy/Anaphylaxis Action Plan Asthma Action Plan Medication Authorization — if you must take medication at school Anchorage School District  Physical Exam Form— for school entry Sports Activity Exam Form — for athletic participation Allergy/Anaphylaxis Action Plan Asthma Action Plan Seizure Action Plan Long Term Request for Prescription Medication — for use at school Authorization to Self-Carry Medication Medical Statement to Request Special Meals/Accommodations Link to ASD General Nurse’s Forms (those not requiring a doctor’s signature)