Forms/Policies

Forms

Make your office visit easier! This will speed up the paperwork and shorten the time it takes to see one of our pediatricians. If you don’t have Adobe Reader™ please download it here. It is a free software application.

Vaccine Policy Statement

Our clinics policy about the need for vaccinations for children and adolescents.

Patient Authorization Form for Medical Services

This form is needed on the patients first visit. This form can be filled out within Adobe Reader™ and printed out. This will speed up the administrative process and shorten the time it takes to see one of our pediatricians.

Who Should I Call When the Clinic is Closed?

This form is a contact list of phone numbers when the office is closed.

Sports Physical Form

This form is used for a child looking to qualify for sports.

Authorization to Release Protected Health Information

Please fill out this form to have your child’s records transferred to Mendakota Pediatrics from another clinic or hospital.