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.
New Patients
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
Patient Forms
New Patient Forms: Please print, complete and sign these forms, and bring them 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 Records:
- Request a personal copy of your Cloverleaf Pediatrics medical records
- Request to have your Cloverleaf Pediatrics medical records sent to another physician or third party
Virtual Visits:
Current Patients
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.)
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| Consult or Medication Check for Anxiety/Depression: | Patient Health Questionnaire (PHQ-9) (PDF) Generalized Anxiety Disorder (PDF) |