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Patient Demographic Forms
Please print and complete a new patient information form before arriving at your first appointment.
Patient Demographic Form – Under 18 Years For multiple children, please leave the patient name and date of birth blank, fill out one copy, then we will make a copy for each additional child and have you enter the names and date of births at that time. This is to save you time from filling out multiple forms.
Patient Demographic Form – Over 18 Years Patient must fill out and sign, not the parent, now that they are over 18 years of age.
Medical Record Release Authorization Forms
If you are joining Carmel Pediatrics, please obtain health records and vaccine information from previous health care providers before your first appointment.
If you are leaving Carmel Pediatrics, we are so sorry to see you go! Please note there is a $10 labor fee to transfer records.
If you need a form completed by Carmel Pediatrics for sports, camp, daycare, etc. please print and complete the authorization below.
For your convenience:
Beginning January 1, 2018, all physician offices are required under Indiana state law (HB 1273) to have a parent fill out and sign a referral waiver prior to being sent to a specialist. We realize this will be an inconvenience for many, and we apologize for this. To expedite your referral, please sign the form below and fax/bring into our office, and then we will be authorized to release information on where to send your child to. If you have questions, please call our office.
Child Care Authorization
If someone other than a biological parent who is over the age of 18 (includes siblings) brings a child into the office for care, we must have authorization from a biological parent. There are a few different ways to do so, and it must be in writing:
- Biological parent lists these individuals on the patient demographic form that is updated annually;
- Write a letter giving authorization for a particular person;
- Or, CLICK HERE fill out a form and then fax/mail back to us.