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609 Price Ave # 104
Redwood City, CA 94063
650-365-1109
[email protected]

650-365-7720 fax

Patient Forms

We are also happy to offer you the option to download, print and complete our office forms to reduce wait times during your first appointment.

• Registration
• Medical History
• Pre Participation Physical Evaluation-required for all patients ages 11 years old and above at the annual exam every year
• Release of Medical Records-when you need a copy of your records or are transferring to a new pratice/physician

**For patients that were with KKA patients and are transferring to Pediatric Wellness, A CD will be made of the records we have here from May 2011 to present.(RWC Pediatric records). KKA records will be hand delivered to Pediatric Wellness by our staff and signed for so that they have all the original records. The fee you are paying will cover the cost of a CD of records May 2011 to current (RWC Pediatrics records) and delivery of the original KKA records to Pediatric Wellness.

• Authorization for use and Disclosure of Medical Information- when you are joining our practice or need records from a specialst or facility for our physicians to review.

• Patient Partnership Plan

• Vanderbilt Teacher- if you need for an ADHD evaluation
• Vanderbilt Parent- if you need for an ADHD evaluation

• Privacy Practices (this document is for your records)
• HIPPA Acknowledgement Form (This form is required to be on file at our office for all families)

In order to view or print these forms you will need Adobe Acrobat Reader installed.
Click here to download it.

CONTACT US

Questions or Comments?
We encourage you to contact us whenever you have an interest about our services.