Forms
Patient Forms
Before signing the Consent and Acknowledgment page, please review our Patient-Provider Agreement, Patient Financial Responsibility Agreement and Notice of Privacy Practices.
New patients: newborn to 2 months
These forms are filled in and signed together, in one sitting.
- Patient Registration Form
- Medical Decision and Records Authorization
- First Time Newborn (up to 2 months old)
New patients: 2 months and older
These forms are filled in and signed together, in one sitting.
- Patient Registration Form
- Medical Decision and Records Authorization
- Past Medical History Form (2 months and older)
- Records Release – Incoming (if needed, to send us records from your previous doctor)
Established patients (under 18)
Choose the forms you need. You'll fill them in and sign them together.
- Records Release – Incoming (to transfer records to our office)
- Records Release – Outgoing (to send records to another provider)
- Patient Registration Form (update)
- Medical Decision and Records Authorization
- Past Medical History Form (2 months and older)
- Personal Records Request
- ADHD Assessment (Vanderbilt) – Parent
- ADHD Follow-up (Vanderbilt) – Parent
Expecting parents
Prior to your prenatal visit, please complete the forms below. You may use the first name “Baby” and the birth date 01/01/2001 for now.
These forms are filled in and signed together, in one sitting.
- Patient Registration Form
- Medical Decision and Records Authorization
- Prenatal Visit
18 years and older (current patients)
For current patients who are 18 or older. We don't take new patients 18 and older.
Choose the forms you need. You'll fill them in and sign them together.
- Patient Registration Form (18 and older)
- Authorization for Family Member/Proxy Access (18 and older, as needed)
- Records Release – Incoming (18 and older, as needed)
- Records Release – Outgoing (18 and older, as needed)
- Personal Records Request (18 and older, as needed)
These secure forms are for your convenience. You may also securely request appointments, refills, and referrals, review your child’s medical records and immunizations and ask medical questions through our patient portal called Passport. If you are not already set up on this, please contact our office at 808-263-8822 or email admin@reispediatrics.com for assistance.