Forms

Patient Forms

When visiting a new pediatrician, it can be hard to fill out paperwork with a child on your hands. That’s why we have provided most of our patient forms below. Feel free to complete these forms prior to your appointment and return them to the office in-person, by mail, or by fax.


If you are a current patient, we have compiled additional forms you may need throughout the year. If you have any questions about our patient forms, our Fort Collins pediatric team is always available to provide the answers you need.


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Printable Forms

Click on the buttons below to download our new patient forms.
New Patient Forms

In order to provide the best care for your child, it is important that we have any prior medical records from previous physicians. Please download and complete the following forms to make your first visit as smooth as possible. Bring your completed paperwork to your appointment or fax it to our office prior to your appointment.


Note:  Be sure to include a copy of your child’s most current vaccine records.

General Forms

Please fill out this form with as much information as you can and drop it off or email a scanned version to our office. We will return the completed form in about 48-72 hours.

To transfer records TO Pediatric Associates FROM another office

To transfer records TO another office FROM Pediatric Associates

For another person to bring your child in for care (grandparent, nanny, friend, etc.)

Sports Forms

Please fill these out completely before submitting to our office or coming in for your physical.

Ages and Stages Questionnaires

Closely monitoring developmental progress in infants, toddlers, and school-age children is one of our most important jobs. We screen children at every wellness visit from two months of age until they are five years old using the ASQ standardized testing tool. After age five, development is monitored through our discussions during wellness visits.


Prior to each of your child’s well-care visits, please log into the ASQ website online and fill out the screening questionnaire appropriate to your child’s age. Once it is submitted, it will be scored and incorporated into your child’s medical record. Your provider will review the results with you at the well-care visit. If you have any questions, please contact us.


This ASQ link is also incorporated into our free mobile app! Search for “PANC” in your app store and download it today to get started.

ADHD Evaluation Forms

Attention Deficit Hyperactivity Disorder (ADHD) Evaluation forms:


Please drop these off to our office prior to your child’s ADHD evaluation.

Well Care Forms

Please print and fill out the forms below for your child’s Well Care Visit.

You can also print the PDF below and bring to your office visit. If it is a telehealth visit, please scan and email the form to info@pediatricassociatesnc.com.

For 18 and 24 month well care visits

For 2-4 week, 2 month, 4 month, 6 month well care visits

For all visits 12-21 year well care visits

For the 12-13 year well care visits

For the 14-21 year well care visits

Anxiety Evalution Forms

Please fill out this form prior to your child’s anxiety evaluation visit.

For the 14-21 year well care visits

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