UPDOX - PATIENT PORTAL - Publicforms

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Available Forms

12 Month Old Milestones 15 Month Old Milestones 18 Month Old Milestones 2 Month Old Milestones 24 Month Old Milestons 36 Month Old Milestones 4 Month Old Milestones 48 Month Old Mileston 6 Month Old Milestone 60 Month Old Milestones 9 Month Old Milestones Abnormal Involuntary Movement Scale (AIMS) Adult ADHD Form Adult Anxiety scale Adult depression questionnaire Bed wetting Child ADD/ADHD Demo Adult Demo Child Depression screening (Child) Headache Intake KHSAA COVID-19 Return to play Narrative description of child (parent) New Patient Information New Patient Information Pediatric health assessment form - 11 to 14 years Pediatric health assessment form - 2 to 3 years Pediatric health assessment form - 4 to 5 years Pediatric health assessment form - 6 to 10 years Pediatric health assessment form-15 to 18 years Pediatric health assessment 15-18 months Pediatric health assessment 19-23 months Pediatric health assessment 2-4 months Pediatric health assessment 5-7 months Pediatric health assessment 8-14 months Pediatric Symptom Checklist Youth 12-17 Pediatric Symptom Checklist Youth 6-11 PHQ- 9: Modified for Teens Record Release (from us) Request of Prior Records Screen for Child Anxiety Related Disorders (SCARED) (to be filled out by parent/guardian) Suicide Risk Screen ASQ tool

Demo Adult

Demographics Update (Adult)

Please fill in the following information. If you do not know something off hand type N/A.

Name *

Date of Birth *

Mailing Address *

Cell Phone *

Email

Preferred Pharmacy *

Emergency Contact Name

Emergency Contact Phone Number

Insurance Information

Name of Insurance Company *

Policy Holder Name *

Policy Holder Address

Policy Holder DOB

Policy Number *

Group #

This is a direct assignment of my rights and benefits under this policy, I agree to pay and charge not paid by insurance. A photocopy of this agreement shall be considered as effective and vail as the original. I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in the case. I have received a copy of HIPPA ( Health Insurance Portability and Privacy Act) and agree to this policy.

Signature *

Todays Date *

* Required field