Forms

Welcome to DLC Pediatrics, if you are transferring to our office or you want to update patient information, check the forms below. Click to download:

New Patient Forms:

• Registration 
• Privacy Notice (HIPPA)
• Notice of Patient Privacy Practice Policy
• Financial Policy Sheet
• Investment Letter
• Patient Portal Consent
• Physician Assistant Disclosure
• Preventative Co-pays

Transfer or Request Records Forms:

• Medical Record Release Form (From Clinic to Clinic)
• Medical Record Release Form (From Clinic to Patient)

Please fill out the forms and return them to the office.