General Forms

Some forms are also available to fill out online through our Patient Portal.

Privacy Notice
Privacy Notice Receipt
Preauthorization for Adolescents (to come to office alone)
Patient Registration (Spanish)
Patient Registration
Patient Registration (for patients aged 18 or older)
Family History
Immunization Schedule
Consent for Proxy (Permission for Alternate Caregiver)

Pre-participation forms

Kindergarten or Elementary school form
Virginia High School League Athletic Participation Form (Spanish)
Virginia High School League Athletic Participation Form
(fill out completely before coming to office)

Medical authorization

Albemarle County
Charlottesville City
Fluvanna County
Greene County
Louisa County – Jouett Elementary School
Louisa County – Trevilians Elementary School
Louisa County High School
Orange County Public Schools

Release of information forms

Information coming to Pediatric Associates
Main/Adolescent Office
North Office
West Office

Information being sent from Pediatric Associates
Main/Adolescent Office
North Office
West Office

Check up forms

Family history form
Prenatal form

12 month visit
Tuberculosis screen

18 month visit
MCHAT (autism) screen
MCHAT (autism) screen – Spanish

2 year old visit
MCHAT (autism) screen
MCHAT (autism) screen – Spanish

5 year old visit
Tuberculosis screen

College check up
Tuberculosis screen