Patient Forms

ATTENTION: WE ARE CURRENTLY ON A WAIT-LIST FOR NEW PATIENTS OVER THE AGE OF 2 YRS OLD!  ALL NEW PATIENTS/FAMILIES PLEASE FILL OUT THE PRE-REGISTRATION FORM. WE WILL BE TAKING THE PATIENTS FROM THE WAITLIST IN ORDER

New Patient/New Family Pre-Registration Form (Click Here)  We will contact you once all documents are received and we have reached your name on the wait-list. Thank you for your patience. If you are pre-registering a newborn, please call for the first appointment once discharged from the hospital.

Once you have scheduled your first visit, items 1-4 below need to be completed and returned to us. Items 5-7 below are for your information and do not need to be returned to us.

  1. Consent Checklist for Minor Children (rev 8/2020)- Please complete and print
  2. New Patient Demographic Form (rev 8/2020)- Please print and complete
  3. Patient Portal and CHADIS Form (rev 1/2021)- Please print and complete
  4. Credit Card on File Form (rev 8/2020) - Please complete and print
  5. Policies and Fees - (rev 4/2022)
  6. Financial Policy  - (rev 8/2020)
  7. Notice of Privacy Practices - (rev 8/2020)

  Adolescent (11-17y) Patient Portal Form

Request for Release of Medical Records (from another Dr. to us)

HIPAA Privacy Form (Patients 18y or older) - To be completed by the 18+yr old Patient

You may be asked to bring in a completed parent and/or teacher Vanderbilt form for your child's upcoming ADHD appointment. You can find these forms by clicking on the links below.


Office Hours

  
Monday: 08:30 AM - 05:00 PM
Tuesday: 08:30 AM - 05:00 PM
Wednesday: 08:30 AM - 05:00 PM
Thursday: 08:30 AM - 05:00 PM
Friday: 08:30 AM - 05:00 PM
Saturday - Sick only: 08:30 AM - 11:00 AM

If you or your child needs to be seen outside our scheduled office
hours, we recommend using PM Pediatrics.
Please call the answering service first as our doctors may be able to assist you over the phone or via Telemed.
Headed to Urgent Care? Headed to the Emergency Room?

Contact Us

Please use the phone or fax number below to contact the office:

Phone (301) 774-4100
Fax (301)774-7648

Olney Location

(301) 774-4100
18111 Prince Philip Drive Suite 311
Olney, MD 20832