New Patient Office Forms

Patient Forms

In our continuing effort to provide you with outstanding service, we have switched to an Electronic Medical Records system (EMR). This streamlines and enhances record keeping, allowing us to access information more quickly, track referral status more efficiently, and stay current on insurance and billing information. 

If you haven't already done so, we will be asking you to complete a new demographics sheet, and will be obtaining photographs of  your child for our records. Please arrive early for your appointments to allow time for this process.

Thank you!

 

Unless otherwise noted, the following forms are in Adobe PDF format. Clicking on the links will open the form in a new tab or window.  From there, you may print the forms on your printer.  Simply close the tab or window to return to this page.

 

NEW PATIENT PACKET:

Please complete the packet to its full potential.

• New Patient Packet

 

ANNUAL FORMS PACKET:

Please complete the packet to its full potential.

• Yearly Forms

 

NEW BABY OR NEW BORN PACKET:

Please complete the packet to its full potential.

• New Baby OR New Born Packet

OFFICE POLICY FORMS

• The Children's Clinic of Klamath Policies
• CCK Financial Policy
• Discount Fee Policy
• Genetic Privacy Notice
• Non-Discrimination Policy
• Notice to Patients
• Notice of Privacy Practices (HIPAA)
• Early Childhood Intervention Records Release Form
• Authorization to Treat in the Absence of Parent or Guardian

If you need a copy of your child's records for yourself or to be sent to another provider please complete the following form. And remember this process may take up to 30 days: 

• Authorization to Release Medical Information FROM The Children's Clinic of Klamath