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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


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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