FORMS

Accurate contact information is important in case of emergency and for important insurance matters. Please inform Lynn Keefe, MD Pediatrics if any information changes.

Sign this form to have your records transferred from your current pediatrician to Lynn Keefe, MD Pediatrics.

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.

Please review, initial and sign this form prior to your first visit.

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.

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.

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.

Please complete this form if you have daycare or preschool age children.

Sign this form to permit Lynn Keefe, MD Pediatrics to transmit your medical records to another healthcare provider.

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.

• Patient Health Questionaire
• SCARED Rating Scale – Parent and Child

Please fill out before coming to the clinic.