New Patients
Welcome to Chapin Pediatrics!
We consider it an honor and privilege to be chosen to serve as the healthcare provider for your child. If you are a new patient that has received confirmation from us to join our family you will find the forms below helpful. Filling out the forms prior to your first visit and bringing them with you will assist in the new patient processing.
If you have any questions about these forms or anything in general, please do not hesitate to contact our office. If you are on social media sites, please make it a point to follow us/like us as we attempt to use all means possible to communicate and keep you informed.
Again, we thank you for the privilege to serve you.
New Patient Forms
| Patient Demographic Form | PDF (updated: 2018 September) |
| Financial Policy | PDF (updated: 2018 September) |
| Authorization Form – HIPAA | PDF (updated: 2018 September) |
| Records Request-Release | PDF (updated: 2018 September) |
| Authorization to Treat a Minor Patient in Absence of Parent or Guardian | PDF (updated: 2018 September) |
| Notice of Privacy Practices – HIPAA | PDF (updated: 2018 September) |
| Receipt of Privacy Notice – HIPAA | PDF (updated: 2018 September) |
