New Patient registration Forms & Other Forms

image: no show policy No Show Policy English Spanish
image: HIPAA notice of privacy practices HIPAA Notice of
Privacy Practices English Spanish
image: medical release form Medical Records Release English Spanish
image: CHPD Gateway Application CHPD Gateway Application English Spanish
image: NICHQ Vanderbilt Parent-Teacher NICHQ Vanderbilt
Assessment Scale English Spanish
image: Patient and Account Discharge Policy Patient and Account
Discharge Policy English Spanish

ADHD Appointments:

Below are the forms for ADHD appointments. Please complete packet and bring paperwork to the registration office in Suite 100 prior to your child's ADHD appointment. If your doctor is Dr. Michele Kielty please complete the NICHQ Vanderbilt Assessment also.

image: adhd school packet santa maria bonita school district Santa Maria Bonita
School District
ADHD School Packet English Spanish
image: adhd school packet all other school districts All other school districts
ADHD School Packet English Spanish