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.
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
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.
You may print copies of your health form via Patient Gateway after you have received your initial health form from the practice.
ADHD Assessment Form
Upon request from your PCP please follow this link and complete pages 2 through 5.
Vanderbilt Forms Link
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
18+ Year Authorization Form
Once your child turns 18 years old medical information release form is needed for parents to request access to their child’s records. The 18 year old must sign the form granting permission to share their health information if they choose to do so.
18+ Years Authorization Form (pdf)
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.
Patient Information Form
Insurance Waiver Form
Authorization for Vaccine Administration
Family History Summary