Forms

Change of Address Form
If you have moved or your phone number has changed, please use the link below to fill out a form to let us know your new address and phone number.
Click here to fill out a change of address form online.


Health Form

A health form is the most recent report of your child’s latest physical exam and contains his or her record of immunizations. It is usually required by camps or schools before your child attends. Most camps and schools require that your child have had a physical examination within the 12 months preceding attendance.

Our policy has changed effective July 1, 2008, there is no longer a charge for receiving a yearly health form. This may now be requested at the time of your child’s well visit or by calling our office and requesting to have this form ready for pick up or we may fax it to you.

You may print copies of your health form via Patient Gateway after you have received your initial health form from the practice.


Referral Request Form

Below is a link to our online referral request form as well as links to important information about the referral process.
Online Referral Request Form
Download Printable Form (pdf)
How to Request a Referral


Medical Record Release Form

Below is a link to a printable (PDF) copy of our Medical Record Release Form as well as a link to instructions on where to send this form.
Download Printable Form (pdf)
Medical Record Release Instructions


Parent Permission Form

The Parent Permission form should be filled out when you wish to allow someone, other than a parent, permission to bring your child for care at Centre Pediatric Associates, PC.
Download Printable Form (pdf)


New Patients
If you wish to transfer your care to our practice, please complete these forms.
Authorization for Vaccine Administration
Family History Summary
Patient Information Form