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1-833-PDX-KIDS Resources Locations + Quick Links
Beaverton

(503) 531-3434

Gresham

(503) 667-8878

Happy Valley

(503) 261-1171

NW Portland

(503) 295-2546

Bridgeport

(503) 214-2064

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  • Newborn ›
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New Patient?

Patient Forms

New Patient Forms

New Patient Packet
This packet includes all six forms you need to join Metropolitan Pediatrics. Welcome aboard! For expectant families, we ask that you wait to complete the forms until you know baby’s birthday. Please review our Treatment Consent, Billing & Financial Policies, and Notice of Privacy Practices before signing the forms.

Learn more about what to expect as a new patient.

COVID-19 Vaccine

Your whole family ages six months and older can get vaccinated at Metropolitan Pediatrics. Call 1-833-PDX-KIDS to schedule or book your visit online.

COVID-19 Vaccine Screening & Consent
This screener helps us determine if there is any reason you should not get the COVID-19 vaccine. You may complete it and bring it with you to your appointment. Paper copies are also available at the clinic if needed.

Other languages: Spanish

COVID-19 Vaccine Aftercare
This handout goes over what to do if you have a reaction to the COVID-19 vaccine and how to share your vaccine experience with the FDA/CDC for ongoing safety monitoring.

Other languages: Spanish

COVID-19 Vaccine Emergency Use Authorization (EUA) Fact Sheets for Recipients
These handouts provide certain vaccine-specific EUA information to help people make an informed decision about vaccination. The fact sheets are similar in purpose and content to vaccine information statements (VIS) for licensed vaccines.

Clinical Forms

MyHealth Proxy Access
This form gives a proxy, or person other than the patient, permission to access the patient’s MyHealth account and medical information available within MyHealth. Patients 14 and older must give permission for a parent or legal guardian to have access to their MyHealth account, or they can have their own private MyHealth account.

Learn more about MyHealth and viewing family member accounts.

Child & Family Health History
This form asks about diseases and health conditions in your family.

Other languages: Spanish

Behavioral Health Forms

Phone/Video Visit Consent
This document contains important information about engaging in our clinic’s behavioral health services using the phone or internet. Please review it prior to your first virtual visit.

The following forms may be used as part of our evaluation process for a variety of behavioral health concerns, such as ADHD, anxiety, or mood challenges. Your answers will give our team valuable insight into the child or teen’s medical and family history, functioning at home and school, and any concerns related to sleep, attention, and concentration. Please follow your pediatrician’s guidance regarding which forms to complete.

INSTRUCTIONS: Please download the questionnaire to your computer, complete it, and save a copy for your records. Return completed forms to the clinic via MyHealth (as a message attachment), mail, or fax.

Parent Forms

  • Child & Family Information
  • Vanderbilt Assessment Scale (Vanderbilt-Caregiver)
  • Screen for Child Anxiety Related Disorders (SCARED-Caregiver)
  • Pediatric Sleep Questionnaire
  • Children’s Sleep Habits: Ages 5-12
  • Child & Adolescent Trauma Screen (CATS-Caregiver): Ages 3-6
  • Child & Adolescent Trauma Screen (CATS-Caregiver): Ages 7-17

Patient Forms

  • ADHD Self-Report Symptom Checklist
  • Screen for Child Anxiety Related Disorders (SCARED-Patient)
  • Adolescent Sleep Hygiene Scale: Ages 13+
  • Child & Adolescent Trauma Screen (CATS-Patient): Ages 7-17

Teacher Forms

  • Vanderbilt Assessment Scale (Vanderbilt-Teacher)
  • Teacher Questionnaire

Acute Visit Forms

PHQ-9 Questionnaire
This questionnaire is a more in-depth screening tool for the presence and severity of depressive disorder symptoms.

Well Visit Forms

1-6 Month Visit

Postnatal Depression Screen
This questionnaire is designed to identify parents who may be experiencing symptoms associated with Postpartum Depression.

Other languages: Spanish

9 Month Visit

9-Month Ages & Stages Questionnaire
This questionnaire is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

Other languages: Spanish

18 Month Visit

M-CHAT-R
This questionnaire assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month visit and again at 24 months.

Other languages: Spanish

18-Month Ages & Stages Questionnaire
This questionnaire is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

Other languages: Spanish

2 Year Visit

M-CHAT-R
This questionnaire assesses your child’s risk for autism spectrum disorders. Metropolitan Pediatrics screens all children at their 18-month visit and again at 24 months.

Other languages: Spanish

24-Month Ages & Stages Questionnaire
This questionnaire is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

Other languages: Spanish

2½ Year Visit

30-Month Ages & Stages Questionnaire
This questionnaire is designed to screen young children for developmental delays—that is, to identify children who need further evaluation and those who are developing typically.

Other languages: Spanish

6-10 Year Visit

Sports Pre-participation Questionnaire
This questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.

Other languages: Spanish | Russian | Vietnamese

11-13 Year Visit

Adolescent Annual Questionnaire
This questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.

Other languages: Spanish

Health History (Ages 11-13)
This questionnaire is completed by patients at each preventive exam during the 11-13 age range.

Other languages: Spanish

Sports Pre-participation Questionnaire
This questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.

Other languages: Spanish | Russian | Vietnamese

14-18 Year Visit

Adolescent Annual Questionnaire
This questionnaire is completed by all adolescent patients at least once a year because substance use and mood can affect your health.

Other languages: Spanish

Health History (Ages 14+)
This questionnaire is completed by patients at each preventive exam during the 14-18 age range.

Other languages: Spanish

Sports Pre-participation Questionnaire
This questionnaire helps assess and ensure patients’ safe participation in organized sports and other physical activities.

Other languages: Spanish | Russian | Vietnamese

More Ages & Stages Questionnaires

12-Month Ages & Stages Questionnaire
This questionnaire 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 visit; however, many parents choose to complete it and bring it with them to discuss their baby’s development.

Other languages: Spanish

36-Month Ages & Stages Questionnaire
This questionnaire 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 NW Portland Office requires this form at your child’s 3-year visit.

Other languages: Spanish

Administrative Forms

Release of Protected Health Information (PHI)
This release gives Metropolitan Pediatrics permission to send, receive, or verbally exchange PHI with another person or practice of your request.

Other languages: Spanish

Genetic Privacy Notice
This notice is about your right to say no to using your child’s health information or biological samples for genetic research.

Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

Other languages: Spanish

Patient Information
This form is used to collect your family’s demographic and insurance information.

Other languages: Spanish

Treatment Consent
This document describes care at Metropolitan Pediatrics, including our confidentiality obligations, insurance agreements, appointment reminders, after-hours assistance, and grievance procedure.

Other languages: Spanish

Billing & Financial Policies
This document outlines Metropolitan Pediatrics’ billing and financial policies for any charges resulting from care.

Financial Assistance Application
This 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.


Winter 2023 Take Care Newsletter

Latest News

‘Tis the Season for Fevers

Oregon is Experiencing a Surge in Respiratory Illnesses

Bivalent COVID-19 Booster Q&A

2022 Monkeypox Outbreak & Pediatric Infections

2022-23 Flu Prevention

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Office Locations

Beaverton
15455 NW Greenbrier Parkway
Suite 111
Beaverton, OR 97006

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

Bridgeport
7213 SW Hazel Fern Road
Tigard, OR 97224

Phone (503) 214-2064
Fax (503) 598-3600

Gresham
25050 SE Stark Street
Suite 300
Gresham, OR 97030

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

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

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

Happy Valley Sunnyside
16144 SE Happy Valley Town Center Drive
Suite 210
Happy Valley, OR 97086

Phone (503) 486-7040
Fax (503) 658-3377

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

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

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