Patient Forms

Need a well visit appointment, paperwork, or medication refill?

Go to our Patient Portal.

Office Forms

ADHD Forms

COVID Consent Form

Financial Policy

Flu Consent

Foster Care

Notice of Privacy Practices

Records Release

Sports Physicals

ADHD Information Sheet
Guidelines for ADHD Scheduling
Required form for ADHD stimulant medications.
New patients must review and acknowledge this form.
Please sign this form and bring it into the office at your first visit
Find answers to your FAQs on Billing here
Flu Vaccine Consent Form
Please fill out this form for any new foster children you are caring for.
This form shows how we use and secure your protected health information (PHI). It must be reviewed and signed by new patients.
All patients 18 years and older need to fill this out so we have permission to release records and talk to their designated family members. This includes access to the portal.
Please fill this out to get records from outside physicians, clinics, hospitals and school psychologists.
Consent to Treat Form
Print and fill out pages 1-4 if your child plays middle school sports in Kentucky. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.
Print and fill out pages 1-4 if your child plays high school sports in Kentucky. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.
Print and fill out pages 1-2 if your child plays high school sports in Ohio. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.
Print and fill out pages 1-2 for your high school student playing sports in Indiana. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.
The Kentucky High School Athletic Association along with the Kentucky Medical Association has updated their guidance on returning to sports after COVID 19 infection, with the potential reduction of isolation from 10 days to 5. The easiest way to count this is: Day 0 is the first day symptoms occurred or a positive test if asymptomatic. Day 5 is the last day of isolation. Day 6 is the first day that the athlete could potentially return. Athletes also cannot be cleared to return in KY until they have met the following criteria: All symptoms (cough, shortness of breath, fever (≥100.4F), etc.) have resolved for at least 24 hours for mild cases or 7 days for moderate cases without the use of fever-reducing medication. We can see you for the clearance exam on Day 5 or 6 as above.