Fax: (203) 483-8786
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Patient Forms

Providing excellent care means being able to communicate with our patients effectively and assist them with any paperwork that becomes necessary for that care.

New Patient Forms

  • The Demographic Form gives us up-to-date contact information and outlines the members of your family.
  • The Authorized Representative Form tells us the people you allow us to communicate with regarding your child's care. IMPORTANT: This form does not permit the persons listed to consent to any care your child receives or to ask for your child’s records; it simply allows us to talk with them about your child’s care.

PLEASE PRINT THE 2 FORMS ABOVE AND FILL THEM OUT COMPLETELY. Bringing these forms with you to the appointment will save you time in the waiting room.

Physical Exam Forms

At each physical examination, we provide either a State of CT yellow form for those children in daycare, or a State of CT blue form for school-age children. In addition, we will complete any forms you bring with you to the physical exam. We manage these forms free of charge.

If a form is requested outside of the physical exam, there is a nominal charge to have it processed. We will manage it within a 7- to 10-day period, and call you when it is ready for pickup.

Medication Authorization Forms

We manage thousands of medication authorization forms yearly, and provide these free of charge. Like requested forms, we ask for 7 to 10 days to process them, and will call you when they are ready for pickup.

Late August is a very busy time, as children return to school – we strongly encourage parents to call us early with their form requests to avoid missing school deadlines.