Patient Forms

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’ve supplied links below for you to fill out forms prior to your visit. Please print and fill out the appropriate forms prior to your appointment and bring with you that day.  By printing and completing the appropriate paperwork, you will save time on the day of your child’s appointment.

Well Visit Forms

For all well visit appointments

Forms for your toddler’s check-up

  • MCHAT— please fill out at 15, 18 and 24 month visits

Forms for your teenager’s check-up (patients 13+)

Behavioral Health Forms

New Patients

Thank you for choosing Southdale Pediatrics! The following is a form that we need as we start caring for your family. For your convenience, you may select the link below to print and fill out before your first visit. This form is for both new pediatric or allergy patients.

Parental Consent for Medical Treatment

Illness or emergencies can strike at any time and we want to help you be prepared. 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.

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.

Release of Information

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.

Allergy Forms


Families often need forms completed by their pediatrician for camp, school, or daycare. We are happy to fill these forms out for your children in a timely manner.

**Please allow 7-10 business days for sports, camp, and daycare forms to be completed!