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Office Forms

Patient Information - to be completed by parent or guardian
(Fillable form can be downloaded, edited with Adobe Reader and saved. Then email to This email address is being protected from spambots. You need JavaScript enabled to view it.)
Must be completed annualy or when there has been a change to insurance.

Patient Medical History Form to be completed by all NEW patients

Patient Information for Patients over 18 Years Old

Financial Policy

Release of records from office

Release of records to office

NOTICE OF PRIVACY PRACTICES OVER 18

HIPAA - NOTICE OF PRIVACY PRACTICES

Informed Consent for Telemedicine


School Forms

Preventive Health Care Examination Form

KHSAA ATHLETIC PHYSICAL FOR MIDDLE AND HIGH SCHOOL


ADHD Forms

Vanderbilt Parent Initial Assessment

Vanderbilt Parent Follow Up

Vanderbilt Teacher Initial Assessment

Vanderbilt Teacher Follow Up

 

Emotional & Behavioral Health Evaluation Forms

To be completed when requested by doctor or if you have special concerns and you feel it is needed for your child.

Pediatric Symptom Checklist (Emotional Well Being)

Modified Overt Agression Assessment

OCD - Parent Checklist

OCD - Teacher Checklist

Patient Health Questionnaire for Depression

Anxiety Disorders - Parent (Only to be completed by parent, without child input.)

Anxiety Disorders - Child (Only to be completed by child, without parent input.)

 

 

Drs. Bishop, Adams, Poon and Young
Nurse practitioner Elizabeth Combs
45 Cavalier Boulevard
Florence, KY 41042
Phone:          (859) 371-7400
After Hours: 1-866-985-5663
Fax:              (859) 371-8472
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