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 you, your children, and anyone who is allowed to seek care for your child.
Please arrive early for your appointments to allow time for this process.
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.
ACTIVITY FORMS (Fill out and bring with you to your child's appointment)
- Boy Scouts of America (BSA) Class 1 & 2 Personal Health and Medical Record Form (link directs to BSA website)
- Girl Scouts of Oregon & Southwest Washington Permission Slip & Health History Form (link directs to GS website)
- Oregon Sports Physical Form (Parents' Side Needs To Be Filled Out Before You Come For The Appointment)
- Pop Warner Physical Fitness and Medical History Form
CONCUSSION RELATED INFORMATION
- Concussion Information Page
- Pre-Concussion Assessment
- Post-Concussion Assessment for K - 6th graders
- Post-Concussion Assessment for 7th - 12th graders
DEVELOPMENTAL EVALUATION FORMS
- Ages & Stages ASQ Form (link directs to ASQ Oregon website)
- The American Academy of Pediatrics (AAP) recommends that all children receive autism-specific screening at 18 and 24 months of age. Modified Checklist for Autism in Toddlers (M-CHAT) (link directs to M-CHAT website)
NEW PATIENT FORMS:
An asterisk (*) means the form is required.
- Welcome to The Children's Clinic of Klamath*
- Patient Information Form*
- Authorization to Release Medical Information TO The Children's Clinic of Klamath*
- Authorization to Treat Child in Absence of Parent/Guardian*
- Genetic Privacy Notice*
- Notice of Privacy Practices: HIPAA (Health Insurance Portability and Accountability Act)*
- HIPAA Receipt* (Must be reviewed annually)
- Updated Health History (Must be updated annually)
- Abdominal Pain Diary
- Asthma Control Test
- Teen Alcohol & Other Drug Screening Form (CRAFFT)
- Postpartum Depression Scale (EPDS)
- Headache Diary
- Sleep Questionnaire (OSA-18)
OFFICE POLICY FORMS
- The Children's Clinic of Klamath Policies
- CCK Financial Policy
- Discount Fee Policy
- Non-Discrimination Policy
- Notice to Patients
- Early Childhood Intervention Records Release Form
- 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