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) 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

3-21 Year Wellness Exam

Well Child Visit

Patient Name *

First & Last Name

Date of Birth *

Patient Date of Birth

Date *

Each child and family is unique; therefore, recommendations for Preventative Pediatric Health Care are designed for the care of children who are receiving competent parenting, have no manifestations of any important health problems, and are growing and developing in a satisfactory fashion.

Additional visits may become necessary if circumstances suggest variations from normal. If these variations do occur during my visit and are addressed outside the scope of the Well-Child comprehensive health guidelines, I may incur additional charges. These concerns may include, but are not limited to, procedures, recommendations, treatments and/or consultations of medical conditions.

If portions of my Well Child visit and/or physical examination are not covered by my insurance company, I understand that I will be responsible for any charges not covered, including copayments, deductibles, co-insurance and fees for non-covered services. These non-covered services include, but are not limited to, vision, hearing tests, developmental screenings, etc.

Although the billing department will provide assistance with any insurance processing, it is my responsibility (parent/guarantor) responsibility to understand my insurance benefits and coverage.

I have read the above document and understand my financial responsibility and hereby affix my signature as acknowledgement of this understanding. I certify that I am the patient, the patient's parent or legal guardian and have the authority to sign this waiver. *

I Agree

Guarantor Signature *

First & Last Name

Today's Date *

TB (Tuberculosis) Screening Questionnaire

Please choose YES or NO

1. Does anyone in your home have TB or has had a positive TB test? *

2. Does anyone in your home have HIV? *

3. Does anyone in your home work in a homeless shelter or similar setting? *

4. Has anyone in your home been in a correctional facility, jail, prison, or mental institution in the last 5 years? *

5. Has anyone in your home traveled outside of the country in the past few years? *

6. Was your child or any other child in your home adopted or born in a foreign country? *

If YES, Where?

7. Is there an adult living in your home who was born in a non-US country? *

If YES, where were they born?

8. Does your child visit nursing homes often? *

9. Does your child spend time with anyone who has been in a shelter or uses illegal drugs? *

Were there any additional concerns for the patient today? *

Please note that we may change your appointment from a wellness exam if the patient is sick or has multiple or severe concerns. <br/><br/>Type N/A if no additional concerns

Thank you for completing this form.

* Required field