Whether you and your child are new to our practice or you are familiar faces, knowing what to expect at appointments can help ease worried minds as well as facilitate a better experience at the doctor’s office.
Your First Appointment
A few simple measures will help expedite your first appointment.
- Arrive 20 minutes early — someone will review your paperwork with you.
- Bring important documents, including:
- Insurance cards
- Immunization records
- New patient forms
New Patient Forms: Please print, complete and sign these forms. Be sure to bring them along to your first appointment.
- New Patient Questionnaire (PDF) (past medical history form)
- Newborn Questionnaire (PDF) (family medical history form)
- Prenatal Consultation Form (PDF)
- Patient Demographic Form (PDF) (includes payer information)
- Request Medical Records Release (PDF) (to have records sent from another physician to Cloverleaf Pediatrics)
Medical Record Request Forms:
- Request a Copy of Your Medical Records (PDF) (for yourself)
- Request Medical Records Release (PDF) (to a third party)
What to bring to your child’s appointment
Parents and caregivers of all patients — whether new or current patients — are asked to please bring current insurance cards to each office visit. Co-payments are expected at the time of the office visit.
For your convenience please complete, sign and bring any forms that are applicable to your current visit.
|Age of Child or Type of Visit||Form(s) Needed|
|18 months to 2 years old:||M-CHAT (PDF)|
|30 Month Well Child Check||ASQ-3-30-Month Questionnaire (PDF)|
(This form is required for the visit, Please print, complete and bring to the appointment.)
|11 years and older Annual Physical Exam:||Patient Health Questionnaire (PHQ-9) (PDF)|
|School Physical:||School Physical Form (PDF)|
|High School Sports Physical:||High School Sports Physical – MSHSAA (PDF)|
|Consult or Medication Check for ADHD:||Vanderbilt ADHD Diagnostic Teacher Rating Scale (PDF) (Must have teacher complete.) |
|Consult or Medication Check for Anxiety/Depression:||Patient Health Questionnaire (PHQ-9) (PDF) |
Generalized Anxiety Disorder (PDF)