Mobile Full Width Tablet Small Desktop
  • About
    • About Us
    • Our Providers
  • Our Services
    • 24-Hour Assistance
    • Meet & Greets
    • Newborn & Infant Services
    • In-House Labs
    • Well Exams
    • Complex Care Management
    • Behavioral Health
    • Illness & Injury Care
  • Expectant Parents
  • Resources
    • Our Blog
    • Flu Prevention
    • Immunizations
    • Visit & Vaccine Schedule
    • Teen Resources
    • Wellness Resources
  • Patients
    • New Patient
    • Appointments
    • MyHealth Portal
    • Forms
    • Insurance
    • Billing & Financial Services
    • Pay My Bill
  • Locations
  • Appointments
Schedule AppointmentNew PatientsPay My Bill Call us now
Beaverton

(503) 531-3434

Gresham

(503) 667-8878

Happy Valley

(503) 261-1171

NW Portland

(503) 295-2546

  • About
    • About Us
    • Our Providers
  • Our Services
    • 24-Hour Assistance
    • Meet & Greets
    • Newborn & Infant Services
    • In-House Labs
    • Well Exams
    • Complex Care Management
    • Behavioral Health
    • Illness & Injury Care
  • Expectant Parents
  • Resources
    • Our Blog
    • Flu Prevention
    • Immunizations
    • Visit & Vaccine Schedule
    • Teen Resources
    • Wellness Resources
  • Patients
    • New Patient
    • Appointments
    • MyHealth Portal
    • Forms
    • Insurance
    • Billing & Financial Services
    • Pay My Bill
  • Locations
  • Appointments

Patient Forms

New Patient

Authorization to Release Medical Records
The Authorization to Release Medical Records grants Metropolitan Pediatrics, LLC, permission to send, receive, or verbally exchange medical records with another person or practice of your request.
Genetic Privacy Notice
The Genetic Privacy Notice regards the decision whether to use your child’s health information or biological samples for future genetic research.
New Patient Packet
The New Patient Packet includes all of the forms required to become a patient of Metropolitan Pediatrics. Please review our Treatment Consent, Credit Policy, and Notice of Privacy Practices prior to your first appointment.
Notice of Privacy Practices
The Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. | en español
Patient Information
The Patient Information form is used to collect patient/parent demographic and insurance information. | en español
Patient Intake Form
The Patient Intake Form is a detailed questionnaire about your child and family’s medical history. | en español
Treatment Consent
The Treatment Consent describes care at Metropolitan Pediatrics, including our confidentiality obligations, insurance agreements, appointment reminders, after-hours assistance, and grievance procedure. | en español

Additional Forms

Behavioral Health

Vanderbilt Teacher Assessment
The Vanderbilt Teacher Assessment is a teacher-completed rating scale and questionnaire that assists us in better understanding your child’s functioning within the school setting. It is part of our evaluation process for attention deficit hyperactivity disorder (ADHD).
Behavioral Health Intake Packet
The Behavioral Health Intake Packet includes several detailed questionnaires needed for your first behavioral health appointment. Your answers will give our staff valuable insight into your child or teen’s medical and family history, including any concerns related to sleep, attention, and concentration.

Billing & Financial

Credit Policy
The Credit Policy outlines Metropolitan Pediatrics’ billing and financial policies. | en español
Financial Assistance Application
The Financial Assistance Application is a request to be considered for reduced monthly payments or discounts due to a recent change in financial circumstances or the inability to pay your bill.

MyHealth Patient Portal

MyHealth Proxy Access
The MyHealth Proxy Access Request gives a “proxy” (or person other than the patient) permission to access the patient’s MyHealth account and medical information available within MyHealth. Proxy access is available to the following:
  • Anyone an adult patient permits to be a proxy (spouse)
  • Parent of a minor (birth parent or adoptive parent)
  • Legal guardian of a minor or adult
  • Parent/legal guardian of a developmentally disabled minor or adult patient

Return your completed request to your clinic, or fax it to Health Information Services at 503-466-1858.

Additional Visit Questionnaires

12 Month ASQ
The Ages and Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. We do not require this form at your child’s 12 month appointment; however, many parents choose to complete it and bring it with them to discuss their baby’s development. | en español
36 Month ASQ
The Ages and Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. Our Northwest Office requires this form at your child’s 3 year appointment. | en español

Well Visit Forms

1 to 6 Month Visit

Postnatal Depression Screen
The Postnatal Depression Screen is designed to identify parents who may be experiencing symptoms associated with Postpartum Depression. | en español

9 Month Visit

9 Month ASQ
The Ages and Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. | en español

18 Month Visit

M-CHAT-R
The M-CHAT-R assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month appointment, and again at 24 months. | en español
18 Month ASQ
The Ages and Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. | en español

2 Year Visit

M-CHAT-R
The M-CHAT-R assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month appointment, and again at 24 months. | en español
24 Month ASQ
The Ages and Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. | en español

2½ Year Visit

30 Month ASQ
The Ages and Stages Questionnaire (ASQ) is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically. | en español

6 to 10 Year Visit

Sports Pre-participation Questionnaire
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities. | en español

11 to 13 Year Visit

Adolescent Annual Questionnaire
The Adolescent Annual Questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.
Confidential Health History (11-13)
The Confidential Health History is a questionnaire completed by patients at each preventive exam during the 11-13 age range.
Pediatric Symptom Checklist
The Pediatric Symptom Checklist is a standardized screening tool, in which parents rate how they perceive their adolescent. | en español
Sports Pre-participation Questionnaire
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities. | en español

14 to 18 Year Visit

Adolescent Annual Questionnaire
The Adolescent Annual Questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.
Confidential Health History (14+)
The Confidential Health History is a questionnaire completed by patients at each preventive exam during the 14-18 age range.
Pediatric Symptom Checklist
The Pediatric Symptom Checklist is a standardized screening tool, in which parents rate how they perceive their adolescent. | en español
Sports Pre-participation Questionnaire
The Sports Pre-participation Questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities. | en español

Latest News

And Then There Were Five!

Ask Dr. Doug: Missing Sweet Slumber

Measles FAQ

Measles Cases Confirmed in Multnomah County

Local Measles Activity Increases

New Patients

Thank you for choosing Metropolitan Pediatrics as your child’s Medical Home! Our physicians and staff are pleased to have the opportunity to build a relationship with you, your child, and family.

Get Started

 

Office Locations

Beaverton
15455 NW Greenbrier Pkwy
Suite 111
Beaverton, OR 97006

Phone (503) 531-3434
Fax (503) 645-4544

Gresham
25050 SE Stark Street
Suite 300
Gresham, OR 97030

Phone (503) 667-8878
Fax (503) 667-0310

Happy Valley
9300 SE 91st Avenue
Suite 200
Happy Valley, OR 97086

Phone (503) 261-1171
Fax (503) 253-5989

NW Portland
1130 NW 22nd Avenue
Suite 320
Portland, OR 97210

Phone (503) 295-2546
Fax (503) 790-1248

 

Popular Links

 
  • About Us
  • Our Providers
  • Our Services
  • Expectant Parents
  • New Patient
  • MyHealth Portal
  • Insurance
  • Pay My Bill
  • 24-Hour Assistance
  • Meet & Greets
  • Newborn & Infant Services
  • Well Exams
  • Locations & Contact
  • Appointments
  • Privacy Practices
  • Careers
© 2019 Copyright Metropolitan Pediatrics | Website terms of use