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:
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- 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
