This form is primarily for demographic and billing purposes. If you are okay with having us email you appointment reminders, lab results, or our e-newsletter, please be sure to include this information.
Medical Record Release
When your children have had medical services prior to coming to our office, we ask that you complete the Medical Records Release Form. Parents of newborns do not generally need to fill out a record release.
Note that the group that your children previously received care at may charge you up to 75 cents a page to copy those records. Requesting the whole chart may not be practical. For most children, we can make due with the last six pages of progress notes, vaccine summary, and growth curve.
If your child received care from a specialist, we can help you request office notes, operative reports, and pertinent lab results. We are not aware of specialists that charge for this service.
Pediatric Questionnaire & Check-Up Schedule
The questionnaire is two pages and shouldn't take too long to complete -- especially for infants. It provides essential information on past medical history, development, active symptoms, and family history.
Why bother with check-ups? How often should they be scheduled? And what can I expect? These and other topics are addressed in the check-up schedule PDF.
Bambini Office Policies & HIPPA Form
How long are visits? What happens if it snows, and I can't come in? It's 2 AM and my daughter has a fever, what do I do? I am having a baby in two months and want to schedule a prenatal visit. My son is going to three summer camps, and they each have their own form. I have a high-deductible plan, do you give discounts? I can't take time off work -- can I discuss my son's problems in school with the doctor by email? Lot to consider! Hopefully, our office policy download will address these and other concerns for you.
In 1996, the federal government passed legislation called the Health Insurance Portability and Accountability Act. Quite a mouthful! This law helps protect the privacy of health information. Are you okay with us leaving results to your child's lead level on your answering machine, or sending you the results by email? Then just download, review, and sign this form. If your family situation is a little complicated (custody battle, order of protection, etc.), then you may want to also review the Notice of Privacy Practices (available at the office) and give us more specific guidance.
Integrative Care Survey
Ever been to a chiropractor? Interested in homeopathy? Would you be okay giving herbal remedies to your child? We'd like to know. What about vaccines: does your family strongly support immunizations or do you have serious concerns -- or somewhere in between?
Release Bambini Records
If your children are currently Bambini patients, but you are moving out of area, the kids are now grown & ready for adult medicine, or for any other reason you need a copy of their record sent to another doctor's office, please download this form, complete it, and send it to us. Note that, in certain situations, there may be a fee that must be paid in advance for the records to be copied and released.
Bambini Pediatrics PC
Make your first visit to our office a more relaxed one. Please take some time now to download the PDF files below. To view and print these forms, you will need a PDF Reader. If one isn't not already installed on your computer, this free software can be downloaded here.