M.T. Curry Inc - Publicforms

Available Forms

12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

ADHD Agreement

Your child has been diagnosed with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). Medications used for the treatment of ADD/ADHD are classified as stimulants and are regulated by state and federal law. Your understanding and cooperation with the following guidelines are required for your child to receive medication for the treatment of their ADD/ADHD at M. T. Curry Pediatrics.

Please initial next to each point and provide your signature to indicate your understanding and agreement to the terms of this contract. Please note, if there is more than one legal guardian, both individuals will be required to initial and sign this agreement prior to treatment beginning.

Patient Name *

First & Last

Date of Birth *

Patient DOB

I understand that the medication my child is prescribed is to help control the symptoms of ADHD/ADD in an effort to allow my child to learn and function better socially and is not a ?cure? for ADD/ADHD. *

I understand that stimulant medication use can result in tolerance and dependence. For this reason, I agree to give the prescribed medication to my child as discussed with the provider. *

I understand that after initiation of medication for ADD/ADHD, my child will be seen at M. T. Curry Pediatrics for a medication management and follow-up appointment approximately once every 1-3 months. These visits allow monitoring of growth, blood pressure, heart rate, and screening for medication effectiveness and potential side effects. Medication changes are not made over the phone. *

Medication prescriptions can be called into the pharmacy by your healthcare provider. Requests for medication refills may be submitted when the patient has 7 days or less of medication remaining. Please allow at least 2 business days for the prescription to be written and ready for pick up. *

Stimulant medications are easily abused. I understand that it is my responsibility as a parent to safeguard this medication. I will notify M. T. Curry Pediatrics if the medication is lost, stolen, or rendered unusable. I understand that M. T. Curry Pediatrics will not issue another prescription in this instance. I will not seek to obtain ADD/ADHD medications from any other provider other than M. T. Curry Pediatrics. I understand that in the event of suspected abuse or misuse of this prescription medication, M. T. Curry Pediatrics may be required to file a police report, and my family may be dismissed from the practice. *

I agree to do my part as a parent to help my child overcome the challenges of ADD/ADHD. I will limit my child?s ?screen time? (TV, handheld devices, computer, video games etc.) to no more than a 2-hour daily maximum, outside of school. I realize that children need more sleep than adults and therefore will enforce a reasonable and consistent bedtime. I understand that poor sleep can result in or worsen the symptoms of ADD/ADHD. *

I will help my child succeed in school by providing appropriate supervision and environment for homework activities. I will communicate with my child?s teachers or administrators at least monthly to stay up to date with their progress. I provide consent for M. T. Curry Pediatrics and my child?s school to share information as it relates to my child?s ADD/ADHD. *

I will help my child overcome the challenges of ADD/ADHD by seeking out child behavioral therapy, family therapy, or parenting education. *

I will seek out information and educate myself about ADD/ADHD. There are many publications and resources for parents about ADD/ADHD. We recommend: https://www.healthychildren.org/English/health-issues/conditions/adhd, ?ADHD: What Every Parent Needs to Know, 2nd Edition? by AAP, Michael L. Reiff, MD, FAAP, editor in chief; and ?Cory Stories: A Kid?s Book About Living with ADHA?, by Jeanne Kraus. *

By checking this box you confirm that you understand and agree with the above terms *

Parent/Guardian Signature *

Please type your full name indicating your agreement with the terms above.

Today's Date *

Parent/Guardian Signature *

Please type your full name indicating your agreement with the terms above. <br/><br/>Type N/A if there is only one legal guardian (we must have custody forms on file for this to be accepted)

Today's Date *

Type N/A if not applicable

* Required field