New Patient Forms - Parkview Medical Clinic



Parkview Medical Clinic


The following forms should be completed prior to a visit with Parkview Medical Clinic - New patients and patients who have not been seen in at least 3 years should complete them:


PLEASE COMPLETE ALL 6 FORMS BELOW, NOT JUST THE FIRST ONE!


New Patient Registration Form


Patient Responsibility Form


Insurance Authorization Form


Notice of Privacy Practices


Clinic Policy


Release/Signature Form Release of Information from Previous Clinic(s)



New Patient Forms - Optimal Sports Physical Therapy



Optimal Sports Physical Therapy


The following forms should be completed prior to a visit with Optimal Sports Physical Therapy - New patients and patients who have not been seen in at least 3 years should complete them.


PLEASE COMPLETE ALL 4 FORMS BELOW, NOT JUST THE FIRST ONE!


New Patient Registration Form


Patient Responsibility Form


Notice of Privacy Practices


Release of Information



Medical Records



If you need another provider to send records to us or if you need us to send records to another provider, the following form/s need to be completed, as appropriate:


Medical Record Release - Release TO Parkview Medical Clinic


Medical Record Release - Release FROM Parkview Medical Clinic





Athletic Physicals



2022-2023 Athletic Physical Form



Authorization to Speak to Someone Else



The following form may be filled out if you wish to allow Parkview Medical Clinic staff to speak to someone else involved in your care, such as a family member.


Authorization Form



Routine Physical vs. Medical Appointment



The following form is a handout explaining the difference between a medical visit and a preventative visit. Insurance stipulates payment and guidelines on these visits, not the clinic.


Routine Physical/Preventative vs. Medical Appointment





Workers' Compensation



We require the following form to be completed in full for ALL workers' compensation (Work Comp) claims in order for us to attempt to bill your visit. Failure to complete this form timely will result in your being responsible for the visit.


Workers' Compensation Form



Motor Vehicle Accident



We require the following form to be completed in full for ALL Motor Vehicle Accident (MVA) claims in order for us to attempt to bill your visit. Failure to complete this form timely will result in your being responsible for the visit.


Motor Vehicle Accident Form





Well Child Check Up Forms (Under 3 Years)



The forms below should be completed PRIOR to the well child check-up. You may print the forms here, complete ahead of time and bring to the visit or you may arrive 15 minutes prior to your appointment time and get the forms from our front desk. Please complete the form/s appropriate for your child's age.


0-1 Month Old Check-Up


Mother PHQ-9


Vision Questionnaire



2 Month Old Check-Up


Mother PHQ-9



4 Month Old Check-Up


Mother PHQ-9



6 Month Old Check-Up


6 Month Questionnaire (3 mo 0 days through 8 mo 30 days ONLY)


Mother PHQ-9


Fluoride Varnish Consent



9 Month Old Check-Up


9 Month Questionnaire (9 mo 0 days through 9 mo 30 days ONLY)


Mother PHQ-9



12 Month Old Check-Up


12 Month Questionnaire (9 mo 0 days through 14 mo 30 days ONLY)


Vision Questionnaire



15 Month Old Check-Up

No forms to complete at this visit



18 Month Old Check-Up


18 Month Questionnaire #1

(17 mo 0 days through 18 mo 30 days ONLY)

18 Month Questionnaire #2

(15 mo 0 days through 20 mo 30 days ONLY)


MCHAT


Fluoride Varnish Consent


2 Year Old Check-Up

2 Year Questionnaire #1 (23 mo 0 days through 25 mo 15 days ONLY)

2 Year Questionnaire #2 (21 mo 0 days through 26 mo 30 days ONLY)

MCHAT

Vision Questionnaire


2.5 Year Old Check-Up (30 Months)


Fluoride Varnish Consent



Well Child Check Up Forms (3-7 Years)



The forms below should be completed PRIOR to the well child check-up. You may print the forms here, complete ahead of time and bring to the visit or you may arrive 15 minutes prior to your appointment time and get the forms from our front desk. Please complete the form/s appropriate for your child's age.


3 Year Old Check-Up


3 Year Questionnaire #1 (34 mo 16 days through 38 mo 30 days ONLY)


3 Year Questionnaire #2 (33 mo 0 days through 41 mo 30 days)


Vision Questionnaire


Fluoride Varnish Consent



4 Year Old Check-Up


4 year Questionnaire (42 mo 0 days through 53 mo 30 days ONLY)


Vision Questionnaire



5 Year Old Check-Up


5 Year Questionnaire (54 mo 0 days through 72 mo 0 days ONLY)


Vision Questionnaire


Fluoride Varnish Consent



6-7 Year Old Check-Up


PSC 17 Form


Vision Questionnaire



Well Child Check Up Forms (8-20 Years)



The forms below should be completed PRIOR to the well child check-up. You may print the forms here, complete ahead of time and bring to the visit or you may arrive 15 minutes prior to your appointment time and get the forms from our front desk. Please complete the form/s appropriate for your child's age.


8-10 Year Old Check-Up


PSC 17 Form


Vision Questionnaire



11-14 Year Old Check-Up


PHQ-9A


Vision Questionnaire



15-17 Year Old Check-Up


PHQ-9A


Vision Questionnaire



18-20 Year Old Check-Up


PHQ-9


Vision Questionnaire


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Fax: 952-758-6101