Pedicorp provides these documents for your convenience. Printing and completing these documents before your child's appointments will help expedite the check-in/out process. Forms supplied by State of CT may change faster than we can publish to our website, it is always best to check with your school nurse to see which forms are required for your child's current/upcoming school year; as each school/school district has their our requirements.
- Authorization to treat minor without parent or guardian present patients under age 18
- Patient Information Form to be filled out for new patients, annual exam visits, and when information changes
- Practice Policies and Written receipt of Practice Policies
- Notice of Privacy Practices(HIPPA)
- Written acknowledgement of receipt of notice of privacy practices(HIPPA)
- Sample of Medication Authorization Form (your school/camp may have their own version)
- "Blue" School Form State of CT
- 'Yellow' Pre-school Form State of CT
- Health history for sports participation must be completed prior to exam when child will be participating in sports
- Prenatal questionnaire
- Form for parents of child 9 months to fill out for well exam
- Form for parents of child ages 18 & 24 months to fill out for well exam
- Form for parents of child ages 4 to 10 years to fill out for well exam
- Form for parents of adolescent child ages 11-20 to fill out for well exam
- Electric/Utility Policy
- Request to release medical records TO Pedicorp
- Authorization to release medical information (for any purpose such as transferring out of practice, referral purposes, etc.)