Embedded Files
Forms for new patients
Forms for new patients
Please download or print, complete, and sign. You can email them to info@freetobepediatrics (not secure), send through the portal, or bring to your visit.
Please download or print, complete, and sign. You can email them to info@freetobepediatrics (not secure), send through the portal, or bring to your visit.
Required forms for New patients
Required forms for New patients
These can all be downloaded to complete with a PDF viewer or printed to complete by hand and bring to the office
Initial history form.pdfOne per CHILD, complete one for each child.
You do not need to repeat family history if children have the same parents.
FTBP Office policies.pdfOne per FAMILY, put all children's names and dates of birth on here
Consent to treat, HIPAA, financial agreement.pdfOne per FAMILY, put all children's names and dates of birth on here
HIPAA Policy.pdfTo be read, does not need to be printed or signed
Recommended forms for New patients
Recommended forms for New patients
These give consent for Dr. Korrell to get your past records and do telehealth
Release of info TO FTBP.pdfRecommended to give use permission to request your child's records from prior doctors
One per FAMILY, put all children's names and dates of birth on here UNLESS the children saw different doctors.
Required if doing telehealth now or in the future, recommended for all new patients
One per FAMILY, put all children's names and dates of birth on here
Telehealth consent.pdf.pdfProvidence PCP selection form.pdfTo change Providence PCP, required for billing
Additional forms as needed
Additional forms as needed
These are specific to parent concerns and should be completed at Dr. Korrell's recommendation only
Vanderbilt PARENT.pdfADHD screener
ADHD screener
Parent version
Vanderbilt TEACHER.pdfADHD Screener
ADHD Screener
Teacher version
PPE sports form.pdfSports physical form
Sports physical form
M-CHAT-R_F_March_2025.v2.pdfMCHAT
MCHAT
Autism Screening form
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