Benzel Pediatrics
Forms
Forms & Policies
Prior to your appointment, the forms listed below can be printed for your convenience. Filling them out beforehand will save you time by not having to complete them during your appointment. If you elect not to fill out these forms ahead of time, please arrive 15 minutes prior to your scheduled time.
Annual Patient Packet Forms
Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)
(Medical Records Release)
Patient Portal Proxy Authorization (PDF)
(18 years or older)
Patient Forms
Assessment Forms
Edinburgh Postnatal Depression Scale (PDF)
(Complete prior to the 1 month checkup)
MCHAT, Revised Follow-Up: Checklist Only (PDF)
(Modified Checklist for Autism in Toddlers -
Complete for 18 and 24 month well child checks)
MCHAT, Revised Follow-Up: Packet with Checklist (PDF)
(Modified Checklist for Autism in Toddlers -
Complete for 18 and 24 month well child checks)
PSC-Y Report (PDF)
(Pediatric Symptom Checklist - Youth Report)
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