Patient Forms

  • File

    * Authorization for Treatment

     (416K)
    This form gives us permission to medically treat your child. All new patients must have this form completed.
  • File

    * NPP Acknowledgement Form

     (61K)
    All new patients must have this form on file. This form states that you have received a copy of the Notice of Privacy Practice (NPP). The NPP can be downloaded using the link below, or read online in the policies section.
  • File

    * New Patient History

     (98K)
    A medical history form for all new patients.
  • File

    * New Patient Profile

     (206K)
    This form contains demographic information. All new patients need to have this form completed.
  • File

    Authorization for Release of Medical Information

     (64K)
    Use this form to request a transfer of medical records to OPAM or from OPAM to another facility.
  • File

    Guardian Consent Form

     (56K)
    This form allows someone other than the child's legal guardian to seek healthcare on the child's behalf.
  • File

    Notice of Privacy Practice

     (105K)
    This is a downloadable version of the NPP. This document explains how your personal health information is protected and used.