Forms:

Patient Information Form

Includes financial policy.

Consent by Proxy for Non Urgent Pediatric Care

This form means that you are giving authorization for the people you list to seek medical treatment for your child/children in your absence

Authorization for Release of Medical Information to Santa Rosa Pediatrics.

Knowledge of Receipt of Notice of Privacy Practice

Health Check History Form

Pre-authorization to Treat Minors

Form for those 16 years and older.

Notice

- Please bring your insurance card and vaccine records with you to your appointment.

- Please have the name, address and phone number of your prior doctor so we may get your previous records.

- If this visit is a Physical, please wear lightweight clothing

- If your child is a foster child or adopted, please bring a copy of guardianship records for our office to copy for our records.

SANTA ROSA PEDIATRICS