Pediatric Patient Intake Form

DOUGLASVILLE CHILDREN'S THERAPY SERVICES AND ASSOCIATES
Pediatric Patient Intake Form
Please Note:

This form will take approximately 10 minutes to complete.

Several consent and policy forms within the intake will require your E-Signature.

Please do not print these forms. Please fill them out online 24 hours before our visit. We are a Paperless Practice utilzing Electronic Health Records.

All information is Confidential.

Cancellation Policy:
Please mark the date of your Appointment on your calendar. Missed appointments will be invoiced at $30.00 for one discipline, $45.00 for two disciplines and $60.00 for three disciplines. Extenuating circumstances will be reviewed on a case-by-case basis. A strict twenty-four hour (1 full business day) notice via voice mail and email are acceptable. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation.
Signature*

Clear

Patient Consent Form for Collection, Use, and Disclosure of Personal Information
Privacy of your personal information is an important part of DCTSAA's practice, while providing you with quality care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. All electronic forms and consent forms are viewed only by the staff in DCTSAA unless you have specifically signed a Release of Records to make these forms available to another Health Care Provider or family member. In-office forms at DCTSAA are utilized by the staff of the centre and adhere to the appropriate use and protection of your information.

Our Privacy Policy at the DCTSAA practice outlines what we are doing to ensure that:
- Only necessary information is collected about you;
- We only share your information with your consent;
- Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols;
- Our privacy protocols comply with privacy legislation and standards of our regulatory body.
How our Clinic Collects, Uses and Discloses Patients’ Personal Information:

The Clinic / Practice of DCTSAA understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is using and disclosing your information.

The clinic will collect, use and disclose information about you for the following purposes:
- To assess your health concerns
- To provide health care
- To advise you of treatment options
- To establish and maintain contact with you
- To send you newsletters and other information mailings
- To remind you of upcoming appointments
- To communicate with other treating health-care providers
- To allow us to efficiently follow-up for treatment, care and billing
- To complete claims for insurance purposes
- To invoice for goods and services
- To process credit card payments
- To collect unpaid accounts
- To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others
- To use for educational and research purposes (this includes case summaries, photographs, lab results and other pertinent medical information). Your identity will be protected at all times and if necessary, identifying information will be altered to protect your privacy in all the above instances
By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.
Patient Consent:
I have reviewed the above information that explains how DCTSAA will use my personal information and the steps that the centre / clinic is taking to protect my information.

I agree that the DCTSAA can collect, use and disclose personal information as set out above in the information about the clinic / centres’s privacy policies.
Full Name*

First NameLast Name
Date

MonthDayYear
I have reviewed the above information that explains how DCTSAA will use my personal information and the steps that the centre / clinic is taking to protect my information. I agree that the DCTSAA can collect, use and disclose personal information about (the signed) as set out above in the information about the clinic / centres’s privacy policies. Signature*

Clear

Informed Consent
Please note that this form must be signed prior to your first appointment.
Full Name (of Patient)*

First NameLast Name
Full Name (of Guardian)*

First NameLast Name
Date

MonthDayYear
Signature of Patient or Guardian Indicating that they have read and agree to Informed Consent*

Clear

Nutrition / Diet
Was your infant:

BreastfedFormula-fedOther
How Long?
Which foods were introduced before six months?
Which foods were introduced from 6 - 12 months?
Did your child ever experience colic?

YesNo
How Severe?

MildModerateSevere
Does your child have any dietary restrictions? (Religious, vegetarian / vegan, etc)?
Typical Breakfast
Typical Lunch
Typical Dinner
Snacks
Beverages and Quantity

Health & Development
How was your child's health in the first year?

PoorFairGoodExcellentUnknown
At what age did your child first:
Sit Up?
Crawl?
Walk?
Talk?
Describe your child's sleep pattern? Time to bed, awake, naps, nightmares?
How would you describe your child's temperament?
How would you describe your child's behavior and performance at school?

Please upload your child's current therapy (OT, PT, Speech) prescription here.

Upload a File

Cancelof
Please upload your child's current IEP (Individualized Education Plan) or IFSP (Individualized Family Service Plan) or 504 plan if applicable.

Upload a File

Cancelof
Are there any lab reports, pictures of your child's condition, diet diaries, or review of systems to upload? Please do so here - File 3

Upload a File

Cancelof

Last Question!
How do you view the investment in your child's health?

I really just have an acute concern about my child that I need help addressingI see the importance in having a health care team for my child and assessing their growth and development on a regular basis.Investing in my child's health is as important as investing in their education - it is their future. I would like them to have access to healthcare options when needed, and I see the importance of assessing their growth and development on a regular basis
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DOUGLASVILLE CHILDREN'S THERAPY SERVICES AND ASSOCIATES

Pediatric Patient Intake Form

Cancellation Policy:

Patient Consent Form for Collection, Use, and Disclosure of Personal Information

Informed Consent

Demographic Information

Prenatal Health

Birth History

Health & Development