Covid-19 Reference Handouts
Please download and e-sign the waiver if you will be getting Covid-19 testing done in our office. Email the form to info@myalliancepediatrics.com. –Covid Test Waiver
For those that have close contact with please review this form – Close contact
For those that are a caregiver or have a house hold member diagnosed with Covid-19 – Caring for someone else
For those that have Covid-19 or believe you have Covid-19 – I think I have Covid-19
Patient Forms
Before your appointment with us, quickly and conveniently access patient forms from our practice. Be sure that you bring both your drivers license and health insurance card with you to each visit.
To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com. Please bring your completed forms with you to our office at the time of your visit.
- New Patient Information Sheet – Fill this out and bring with you to your first appointment at the office.
- New Patient Packet – Online Form | PDF | PDF (Spanish Version) (- If your child is under the age of 18 and is new to our practice please fill these out and bring them in to your first visit.
- Financial Policy – Please review and sign and bring with you to your next appointment (last revision 6/2019)
- HIPPA Acknowledgement form. HIPPA Acknowledgement (Spanish)
- HIPPA (Updated Notice of Privacy Practices (9/23/13))
- Portal Registration Form – Fill this out and email it to info@myalliancepediatrics.com or bring it to your next appointment in the office.
- In Office Cholesterol Screening Waiver – If your child is 11 years of age or older please print this form out. This sheet provides information on the cholesterol screening we do in office. If you would like more information on this screen, please read our Cholesterol FAQ.
- Pre-Participation Questionnaire – If your child is 11 years of age and older please fill this form out an bring it with you to your next well visit as well as a copy of the cholesterol screening waiver.
- FHSAA Pre-participation Physical Evaluation – If your high school student plays a sport, print this form out and bring it with you.
- Record Release – Fill this out if you are requesting copies of your records. The office does not charge you for a copy of your records if you are transferring to or from the practice.
- Authorization for alternate consent
