Children First Pediatrics Putting your child's health first
doctors@childrenfirstpediatrics.com
Rockville Office: 301.990.1664 | Silver Spring Office: 301.681.6000
Fax: 301.990.0471


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Forms

Well Child Forms

*TB Questionnaire
*Lead Questionnaire
*MCHAT (Autism Screening Tool)
*EPDS Postnatal Screening (to be completed at 2wk, 1 month and 2 month visit)
*Teen Depression Screening (to be done yearly by the PATIENT from 12yrs -18yrs old)
*Anxiety Screening (Parent and Patient portion at 11yrs and 14 yrs old well visit)

Some of the forms above are developmental and/or important screening forms that we use as a standard of care during certain well visits. These forms will be billed to your insurance for payment. In the event your insurance does not cover this screening, the patient will be billed $15 per form.  Please note that some insurances cover these screenings but charge a copay to the patient.

New Patient Forms

HIPAA Acknowledgement
HIPAA Authorization
HIPAA Privacy Practice
Financial Policy
Patient Demographic Form

Vaccine Information Sheets

*Multiple Vaccines for Infants
*DTaP
*Polio
*Hepatitis B
*Hepatitis A
*Rotavirus
*Prevnar 13
*MMR
*MMRV (MMR and Chickenpox)
*Varivax (Chickenpox)
*HPV-Gardasil for Boys and Girls
*Meningitis
*TDaP

Developmental/ADHD Forms

*Cover Letter for Developmental History Form
*Developmental History Form
*Vanderbilt Parent Initial
*Vanderbilt Parent Follow Up
*Vanderbilt Teacher Initial
*Vanderbilt Teacher Follow Up

School and Camp Forms

*Montgomery County School Form
*Montgomery County Medication Form
*DC School Form
*DC Medication Form
*PG County Medication Form
*PG County School Form

Please allow 3-4 business days for the completion of any school or camp form. There is a $20 fee to fill out your form and an additional $15 rush fee to fill it out sooner than the 3-4 day normal time frame. If you have an upcoming physical for the patient we encourage you to bring the form it at that time so there is no charge for filling out the form. Please make sure the name of the patient is on the form and the parent portion is completed before turning it in to our office. Please do not fill out the physician section and submit to us for a signature only. Doing so still results in a charge of the form fee as we still go over everything to be sure it is filled out correctly.
Note:  the extra $15 rush fee guarantees the form will be completed within 24hrs of when we received it.  For forms received on Friday, we will guarantee the form by Monday for the rush fee.   WE DO NOT GUARANTEE FORMS DROPPED OFF ON FRIDAY FOR SATURDAY OR SUNDAY PICK UP.  Thanks for your understanding.

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