Form Instructions

We need several items of information from you before we can deliver care for your child. We can’t get this information from other places you may have given it, including other providers, the hospital, or previous clinics, due to HIPAA laws and other confidentiality requirements.

In an effort to make it as painless as possible, you may submit the forms below online.

These forms are available in hard copy at Cottonwood Pediatrics. Please DO NOT email these items to us as it is NOT SECURE and could lead to identity theft. If not completed by appointment time, it will need to be completed, and your appointment will be delayed.

New Patient Form – All new patients need the New Patient Information Form completed before their appointment. The Patient Privacy Notice and Consent to Treat will be signed at your appointment. The Optional Form to allow a non-parent to bring your child to an appointment is for your convenience.

Foster Child New Patient Form – if you are a foster parent of a new patient, please fill this form out before their appointment.

Transfer/Release Medical Records Form – This form can be used to transfer records into or out of Cottonwood Pediatrics. It must be FULLY completed.

Step-Parent Consent to Treat Form – when the spouse of a remarried parent brings the child to the clinic

Grandparents Consent to Treat Form – also babysitters, friends, aunt/uncle, etc.

Teenager Annual Consent to Treat Form – must be 16 or older

We reserve the authority to decide, in our sole discretion, to require a parent to be present regardless of any consent a parent may have signed.