Patient Information & Insurance Form
Accurate contact information is important in case of emergency and for important insurance matters. Please inform Lynn Keefe, MD Pediatrics if any information changes.
Authorize Us to Receive Your Medical Records
Sign this form to have your records transferred from your current pediatrician to Lynn Keefe, MD Pediatrics.
New Patient History Form
It’s important for Dr. Lynn Keefe and Dr. Laura Lee to know your complete medical history. Please complete this form prior to your first appointment.
Office Procedures & Patient Charges
Please review, initial and sign this form prior to your first visit.
HIPAA (Under 18 Years)
Sign this form to give consent to the use and disclosure of health information regarding your child under 18 years of age for treatment, payment, or healthcare operation by Lynn Keefe, MD Pediatrics.
HIPAA (Over 18 Years)
Sign this form to give consent to the use and disclosure of health information for treatment, payment, or healthcare operation by Lynn Keefe, MD Pediatrics.
Sports Physical Evaluation Forms
Getting ready for middle school or high school sports? Download and complete these forms prior to your examination at Lynn Keefe, MD Pediatrics.
These forms for parents and teachers are assessment tools for initial evaluations and follow up visits for ADHD or ADD. Please complete them prior to your office visit.
Daycare & Preschool Form
Please complete this form if you have daycare or preschool age children.
Authorization for Us to Release Your Medical Records
Sign this form to permit Lynn Keefe, MD Pediatrics to transmit your medical records to another healthcare provider.
Consent by Proxy
This form gives consents for others to make care decisions for your child on your behalf. This proxy is useful when your child is in the care of another adult, babysitter, grandparent, etc.
Mental Health Screening Forms
Flu Shot Form
Please fill out before coming to the clinic.