Illini Pediatrics LLC, DBA Ideal Pediatrics

Available Forms

2020 - Covid Policy Addendum 2020- Established PT Update 2020- Health History 2020- New Patient Intake 2020- Office Policy/CCOF ACT--Asthma control Test (12yr+) ACT--Asthma control Test (4-11yr) ADHD Parent Follow Up ADHD Parent Initial Behavioral intake (for ages 8 and older) Behavioral intake (up to 7 years old) Complete Packet- 0-5 day (newborn) Complete Packet- 1 month Complete Packet- 10 year Complete packet- 11-14 yr (parent) Complete Packet- 12 months Complete Packet- 15 months Complete packet- 15-17year (parent) Complete Packet- 18 months Complete Packet- 2 month Complete Packet- 24 months Complete Packet- 3 year Complete Packet- 4 month Complete Packet- 4 Year Complete Packet- 5 yr Complete Packet- 6 Months Complete Packet- 6 yr Complete Packet- 7 yr Complete Packet- 8 Year Complete Packet- 8 Year Complete Packet- 9 Months Complete Packet- 9 year Complete Packet- Older Adolescent Packet 15-18 (child) Complete Packet- Younger Adolescent 11-14 (Child) Complete Packet-30 month Covid consent COVID Test- Non Patient Covid Vaccine Registration GAPS 11-14yr GAPS 15-18yr Generalized Anxiety Disorder 7-Item Scale PHQ9 Prevaccination Checklist for COVID-19 Vaccines RAPID TEST ONLY- Patient Intake Release of records TO IDEAL PEDIATRICS SCARED Vaccine Declination Vaccine FLU Contraindications Vaccine Screening for Contraindication Vaccine VFC Eligibility Screening

2020- New Patient Intake

Patient Information

Patient Name

Last, First

Date of Birth

MM/DD/YYYY

Sex: *

Female

Male

Home Address

City, State, Zip

Primary Cell Phone

only number that will receive reminders

Primary Email

Parent/Guardian Information

Parent/Guardian Name

Last, First

Parent/Guardian DOB

MM/DD/YYYY

Parent/Guardian Home Address

if different than patient

Parent/Guardian Phone Number

Relation to patient *

Parent/Guardian Information (second)

Parent/Guardian Name

Last, First

Parent/Guardian DOB

MM/DD/YYYY

Parent/Guardian Home address

If different than patient

Parent/Guardian Phone number

Relation to patient:

Additional Information

List all siblings with dates of birth

Emergency Contact Name and number

Consent for release of information

Adults that can call for patient information excluding financial

Consent for office visits

Adults allowed to bring patient in for appointments

Preferred Pharmacy

Address of Preferred Pharamacy

Insurance information

What type of insurance?

Insurance plan:

ex. United Health Care, Blue Cross, Aetna, Home State Health, Molina etc

Member ID

Group Number

Subscriber Name

Does not apply to medicaid insurnace

Subscriber Date of Birth

Does not apply to medicaid insurance

Secondary Insurance

What type of insurance?

Insurance Plan:

Member ID

Group Number

Subscriber Name

Subscriber Date of Birth

* Required field