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You may download and print any of our forms listed below prior to your visit. You may either bring them with you to your first visit or fax them before your appointment. If sending via fax, please verify with us that we received your forms prior to your visit.  

Our fax number is (972) 475-5708.

 

Some parents have asked if the completed forms can be sent to us via email. You may do this, but please be aware that email is not a secure medium. The information can conceivably be intercepted and read by someone other than Lake Pointe Pediatric Associates. If you would still like to use email, you can send completed forms to

[email protected]

 

Please verify with us that we have received your email prior to your visit.

 

We use encrypted email if we send any protected information to you. The emails we send are automatically deleted 2 weeks after they are sent. Be sure to open them and print or save any information you wish to keep before the 2 week period expires.

 

Patient Care Forms

 

Food Diary Form

 

Dr. Wieland ADHD New Patient Packet

 

Dr. London ADHD New Patient Packet

 

Vanderbilt ADHD - Parent

 

Vanderbilt ADHD - Teacher

 

ADHD Daily School Report

 

ADHD Follow Up

 

Headache and Stomach Ache Questionnaire

 

Influenza Vaccination Questions

 

Tuberculosis and Lead Exposure Risk Questionnaire

 

Well Child Questionnaires

Less Than Two Years Old

 

Two-to-Five Years Old

 

Six-to-Ten Years Old

 

Eleven-to-Fifteen Years Old

 

Administrative Forms:

   New Patient Forms:

 

   Authorization to Obtain Records From Another Provider

 

   New Patient Questionnaire

 

   Patient Information Sheet

 

   Patient Information Disclosure Instructions

 

   Authorization for Treatment of Minors

 

   Notice of Privacy Practices

 

   Payment Terms for Services Rendered

 

Other Administrative Forms:

   Authorization for LPPA to Release Medical Records

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