Patient Forms

Here at Southdale Pediatrics, we know that it can be a time-consuming process to fill out patient forms for you or your child. However, the information you provide is vital to us–we need to have certain background information in order to give your child the best health care possible. We also need certain information for billing purposes, for our medical records department, and to follow governmental guidelines and regulations. That's why we've supplied links below so that you can fill out forms at your convenience.

General Forms

Release of Information Form

The Release of Information form gives us the authority to release your medical records. Patients under 18 must have their parent or guardian sign the form. Those 18 and up need to sign the form themselves. Seven to 10 business days are needed to process the form.

Release of Information

 Consent for Disclosure Form

The Consent for Disclosure form gives other individuals the ability to participate in discussions and decisions related to medical care when the patient is over 18 years old. 

Patients Age 18 and Older Consent for Release of Information 

 Parental Consent for Medical Treatment

Illness or emergencies can strike at any time and we want to help you be prepared. A Parental Consent for Medical Treatment form is wise to have on hand. Whether you're traveling for business, are away for a weekend, or are merely out for a date night, your child's caregiver is not authorized to give consent for treatment for your child without the necessary documentation. The Parental Consent for Medical Treatment form provides the needed information, giving you peace of mind when you're away from your child. Please make sure that your child's caregiver has a copy for each child and brings it to the clinic when needed.

Parental Consent for Treatment

 Wart Treatment

 Information

Consent for Wart Treament

Minnesota Sports League Form

If your child in grades seven through 12 is going to be participating in school athletics, he or she will need the following form filled out before the sports season begins. Please be sure to answer the questions on page two because the pediatrician will need to review these answers before signing the form.

Minnesota Sports League Form

New Pediatric Patient Forms

Thank you for choosing Southdale Pediatrics. The following are forms that we need as we start caring for your family. For your convenience, you may select the links below to print them and fill them out before your first visit.

New Patient History-Pediatric

New Patient Account Registration

 Consent for Services

New Allergy and Asthma Patient Forms

Southdale Pediatrics looks forward to helping you manage your allergies, asthma, and other related issues. For your convenience, new patients may choose to print and fill out the forms below prior to coming in for an initial visit.

New Patient History - Allergy/Asthma 

New Patient Account Registration

Consent for Services

ADHD Forms

Initial Visit

Full Evaluation Packet

Follow Up Visit

Follow-Up Parent Assessment (Vanderbilt Assessment Scale)
Follow-Up Teacher Assessment (Vanderbilt Assessment Scale)

ADHD Medication Refill

When you need to refill your child's ADHD medication, we have a convenient 24-hour prescription service that you can use. The number is (952) 841-8436. We do, however, need certain information in order to fulfill your request, and that is clearly listed in the following link. We need five business days in order to process the request, and it is only for ADD/ADHD medicine.

ADHD Medication Refill