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Office Info
Resources
Is Your Child Sick?®
Locations
- Townsend Office
- North Wilmington Office

Contact

Delaware Pediatrics

Townsend 302-449-2570

Wilmington 302-762-6222

Delaware Pediatrics

Appointments

Patient Portal

Pay My Bill

About Us
Services
Office Info
Resources
Is Your Child Sick?®
Locations
- Townsend Office
- North Wilmington Office

Forms

All Your Patient Forms In One Place

The following forms are here so that you can download and fill out prior to your visit.

Annual Patient Packet Forms

English

Child Registration (PDF)

Pediatric Family Registration (PDF)

Adult Patient Registration (PDF)

Annual Consent and Acknowledgement (PDF)

Notice of Privacy Practices (PDF)

Spanish

Registro de Niños (PDF)

Registro Familiar Pediátrico (PDF)

Registro de Pacientes Adultos (PDF)

Consentimiento y Reconocimiento Anual (PDF)

Aviso de Prácticas de Privacidad (PDF)

Patient Forms

English

18-year old: ADULTHOOD Letter (PDF)

Advocare Beyfortus Patient Liability Form

Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)

Authorization to Bring a Minor (PDF)

Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)

Cancellation of Prior SureScripts: Opt-Out (PDF)

Case Registration (PDF)

Healow Trifold (PDF)

Health Information Exchange (HIE): FAQs (PDF)

Health Information Exchange (HIE): Opt-Out (PDF)

Informed Consent: In-Office Procedures (PDF)

Newborn Insurance Reminder (PDF)

Patient Financial Responsibility (PDF)

Patient Photograph/Video Information Release Authorization (PDF)

Patient Portal Proxy Authorization (Age 18+)

Patient Portal: FAQs (PDF)

Patient Portal: Flyer (PDF)

Practice & Payment Philosophy (PDF)

Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Restriction of Disclosure to Health Plan (PDF)

SureScripts: Opt-Out (PDF)

Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)

18-year old: ADULTHOOD Letter (PDF)

Advocare Beyfortus Patient Liability Form

Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)

(Medical Records Release)

Authorization to Bring a Minor (PDF)

Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)

Cancellation of Prior SureScripts: Opt-Out (PDF)

Case Registration (PDF)

Healow Trifold (PDF)

Health Information Exchange (HIE): FAQs (PDF)

Health Information Exchange (HIE): Opt-Out (PDF)

Informed Consent: In-Office Procedures (PDF)

Newborn Insurance Reminder (PDF)

Patient Financial Responsibility (PDF)

Patient Photograph/Video Information Release Authorization (PDF)

Patient Portal Proxy Authorization (Age 18+)

Patient Portal: FAQs (PDF)

Patient Portal: Flyer (PDF)

Practice & Payment Philosophy (PDF)

Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Restriction of Disclosure to Health Plan (PDF)

SureScripts: Opt-Out (PDF)

Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)

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Forms

All Your Patient Forms In One Place

Annual Patient Packet Forms

English

Spanish

Patient Forms

English﻿

Spanish

Assessment Forms

Required Forms

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