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.
Initial history form.pdfSave as PDF or print, complete, and sign.
FTBP Office policies agreement.pdfSave as PDF or print, complete, and sign.
Consent to treat, HIPAA, financial agreement.pdfSave as PDF or print, complete, and sign.
HIPAA Policy.pdfTo be read, does not need to be printed or signed
Release of info TO FTBP.pdfRecommended to give use permission to request your child's records from prior doctors
Telehealth consent.pdfRequired if doing telehealth now or in the future, recommended for all new patients
PCP change form.pdfTo change PacificSource PCP, required for billing
Providence PCP selection form.pdfTo change Providence PCP, required for billing
Additional forms as needed
Additional forms as needed
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