Illini Pediatrics LLC, DBA Ideal Pediatrics - Publicforms

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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

Covid Vaccine Registration

Covid-19 Vaccine Registration Form

Patient Name *

Patient Date of Birth *

Authorized Adult Name *

Authorized Adult Realtionship *

Today's Date

Home Address *

City *

State *

Zip *

Phone Number *

Insurance Information

Primary Insurance:

Type of Insurance *

Member ID#:

Group #

Some plans, including Medicaid, do not have a group #.

Policy Holder name & DOB:

Secondary Insurance:

Type of Secondary

Member ID#

Group#:

Some plans, including Medicaid, do not have a group #.

Policy Holder Name & DOB

* Required field