Call (325) 695-1600

You may print out and complete the following new patient forms at home and bring the completed forms to your child's first appointment There are eight (8) new patient forms. You do not need to print out form 6, the HIPAA Notice of Privacy Practices. You only need to complete form 8 if you would like to request that medical records be sent to us from previous physicians.

1) New Patient Form
You only need to fill out one of these forms for all of the children in your family.

2) Pediatric Health History Form
Please fill out one health history form for each child in your family.

3) Medical Photography Release/Approval
You only need to fill out one of these forms for all of the children in your family.

4) Formulary Benefits Data Consent Form
You only need to fill out one of these forms for all of the children in your family.

5) ImmTrac Texas Immunization Registry Consent Form
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services. The immunization registry is a secure and confidental service that consolidates and stores your child's (under 18 years of age) immunization records. With your consent, your child's immunization information will be included in ImmTrac. Doctors, pubic health departments, schools and other authorized professionals can access your child's immunization history to ensure that important vaccines are not missed.

6) Texas Vaccines for Children Form 
Your child may be eligible for low-cost vaccines through the Texas Vaccines for Children (TVFC) program. TVFC is a state-operated program funded with federal and state money to provide low-cost vaccines to eligible children from birth through 18 years of age. Please fill out one TVFC form for each child in your family.

7) Acknowledgement of Receipt of Notice of Privacy Practices and Patient Privacy Questionnaire (required) 
New Federal laws require us to provide assurance of privacy and to attest that we will keep your personal and medical information confidentia. You may print out this document, fill it out, sign it, and then bring it with you to your appointment. You only need to complete one form for all of the children in your family.

HIPAA Notice of Privacy Practices (optional)
This document states the HIPAA privacy policy of Adams Pediatrics. (It is not necessary to print this form. Copies are also available at the office.)

Form to Release Medical Records

8) Patient Authorization to Disclosure of Protected Health Information (optional)
If you would like your child's complete medical record to be transferred to Adams Pediatrics, you may print this form, sign it, and bring it to your appointment.(You will need to complete one form for each child.) We will then send your request to your former doctor.

You may also use this form to request records from Adams Pediatrics. Again, print out this form, sign it, and bring or send it to Adams Pediatrics. (One form for each child, please.)

Please note that we will release medical records at no charge if they are to be sent directly to another provider. Medical records released to any other person or entity will be charged according to the rulings set forth by the Texas State Board of Medical Examiners. If you would like to receive a copy of the medical records on disk in .PDF format, the cost will be $5.00 for the entire record plus postage. If you would like to receive a printed version of the record, the cost will be $5.00 for the first 20 pages, and $0.25 per page for each page after 20, plus postage.

ADHD Forms

NICHQ Vanderbilt Assessment Scale – Parent Informant
A diagnostic tool to be completed by the parent and turned in to the doctor for use in determining whether the child has ADHD.

NICHQ Vanderbilt Assessment Scale – Teacher Informant
A diagnostic tool to be completed by the teacher and turned in to the doctor for use in determining whether the child has ADHD.

NICHQ Vanderbilt Assessment Follow-up – Parent Informant
A diagnostic tool to be completed by the parents and turned in to the doctor after the child has been diagnosed with ADHD and treatment has begun, for the purpose of monitoring the treatment.

NICHQ Vanderbilt Assessment Follow-up – Teacher Informant
A diagnostic tool to be completed by the teachers and turned in to the doctor after the child has been diagnosed with ADHD and treatment has begun, for the purpose of monitoring the treatment.

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Click here to download it.

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Pediatrician - Abilene
6300 Regional Plz, Suite 250
Abilene, TX 79606
(325) 695-1600

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