American Kids Care – Pediatric Group

PRACTICE FORMS

• – New Patient Registration Form
• – Medical History Questionnaire
• – Notice of Privacy Practices
• – Record Release form

• – School Entrance Health Form (Commonwealth of Virginia) (MCH-213)
• – Epinephrine Authorization (SS/SE-64)
• – Medication Authorization (SS/SE-63)
• – Inhaler Authorization (SS/SE-65)
• – Sports Participation Form Feb 2017

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WIC – WOMEN, INFANT & CHILDREN

• WIC – 395 form