Patient Forms

We ask all our families to update their Patient Registration Packet annually. 

Thank you for keeping us up to date!

Please complete the necessary sections requiring information or a signature prior to your first appointment to the office. Please note some of the following forms are regarding our office policies and require no completion. These are for your information only.

Other non-required forms you might find useful:

Alternative Caregiver Consent Form

In order to designate another adult to bring your child into our office for medical care in your absence, you must complete and sign an Alternative Caregiver Consent Form. Except for life-threatening emergencies, we are not able to treat your minor child unless he or she is accompanied to our office by a parent, legal guardian or a responsible adult designated on this form.

Release of Medical Records FROM Glendale Pediatrics

You may access your medical records through the Patient Portal. However, if you would like a thumb drive of your medical records, you may use this form to request a copy of your medical records. You may also request this via sending us a portal message. Please be aware that there is a fee for duplication of medical records per patient. An additional fee will be charged if the chart is exceptionally large or if you request that the records be mailed. Please be advised that we do not fax medical records. Records will be provided to you within 15 business days from the date that Glendale Pediatrics receives your written request.

Release of Medical Records TO Glendale Pediatrics

This form can be used to request a copy for your child's medical records from your previous pediatrician or specialist. Please complete and sign the form and give directly to your child's prior physician(s).

In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.