We ask all our families to update their Patient Registration Packet annually.
Please print out the following forms, complete the necessary sections requiring information or a signature and bring them to your first appointment to the office.
Please note some of the following forms are regarding our office policies and require no completion. These are for your information only.
Patient Registration Forms (For Patients 17 years of age and Under)
- Demographic Sheet (Contact Information)
- Consent for Treatment
- Office Procedure and Financial Policy [PDF] [Online Form]
- Credit Card Authorization
- FAQ Regarding our Credit Card Policy**
- Notice of Privacy Practices**
- Patient Information Communication Form
- Alternative Caregiver Consent Form
- Telemedicine Consent Form
** Starred forms are for your information only and do not need to be completed.
Patient Registration Forms (For Patients 18 years of age and Over)
Please have the Patient complete and sign these forms.
- Demographic Sheet (Contact Information)
- Office Procedure and Financial Policy [PDF] [Online Form]
- Credit Card Authorization
- Notice of Privacy Practices**
** Starred forms are for your information only and do not need to be completed.
Alternative Caregiver Consent Form
In order to designate another adult to bring your child into our office for medical care in your absence, you must complete and sign an Alternative Caregiver Consent Form. Except for life-threatening emergencies, we are not able to treat your minor child unless he or she is accompanied to our office by a parent, legal guardian or a responsible adult designated on this form.
Release of Medical Records FROM Glendale Pediatrics
You may access your medical records through the Patient Portal. However, if you would like a thumb drive of your medical records, you may use this form to request a copy of your medical records. You may also request this via sending us a portal message. Please be aware that there is a fee for duplication of medical records per patient. An additional fee will be charged if the chart is exceptionally large or if you request that the records be mailed. Please be advised that we do not fax medical records. Records will be provided to you within 15 business days from the date that Glendale Pediatrics receives your written request.
Release of Medical Records TO Glendale Pediatrics
This form can be used to request a copy for your child's medical records from your previous pediatrician or specialist. Please complete and sign the form and give directly to your child's prior physician(s).
