Forms

These forms are provided to help make your visit to our office as convenient for you as possible. Please bring your completed forms to your first visit, along with your insurance card. Please call our office at 941-552-8341 to learn more.

We look forward to seeing you soon!

Record Release Forms

New Patient Forms

    • Patient Registration Form
      Please complete this form in its entirety before your first visit. This helps us to collect all the demographic, financial responsibility, and legal information we need to properly set up your account. Additionally, it provides documentation regarding who may accompany your child to visits. Patients transferring from other practices

    • Medical History Form – Newborn to 6 Months
      It is very important that you take the time to complete this form for babies up to 6 months of age before your first visit. We use this information to establish any areas of concern or issues that might need to be addressed.

    • Medical History Form – 6 Months & Older
      It is very important that you take the time to complete this form for children 6 months of age and older before your first visit. We use this information to establish any areas of concern or issues that might need to be addressed.

    • Financial Policy
      Information explaining how Weiss Pediatric care treats financial issues.

    • HIPAA Authorization
      This provides authorization for parents, family, friends or advisors to receive medical related communications about your child’s care and appointments as part of your rights detailed in the Health Insurance Portability and Accountability Act.

    • Protected Health Information (PHI) Patient Consent
      This form details the ways in which we can communicate with you and disclose protected health information in order to carry out treatment, payment, and healthcare operations.

    • Immunization Policy
      Information about Weiss Pediatric Care’s immunization schedule. Please refer to the Vaccine Statement for additional information.

    • Vaccine Statement (for reference only)
      As your trusted health care provider, we feel that we have an important responsibility to protect your children, our families and communities from vaccine preventable diseases.