Forms

Financial Policy

Assignment of insurance benefits and authorization to release information

Please complete as much of this medical history form that applies to your child. Family history is on page two and should also be completed.

Record Release to send records to Great Kids Pediatrics

If you are the parent or guardian, who can give authorization to our practice for someone other than a parent or guardian to bring a child into our office, please click here and complete this form.

Please call our front desk staff to ask where you should email this form. (713) 932-6261

• ADHD Parent Initial Form
• ADHD Teacher Initial Form
• ADHD Parent Follow-Up Form
• ADHD Teacher Follow-Up Form

Do you have a school, camp or daycare form that needs to be completed? 

PLEASE COMPLETE YOUR SECTION OR PAGE AND SEND IT via Fax or email with return instructions to Fax: (713) 932-7229 Email:  gkpforms@gmail.com. Our nursing staff will complete it within 2 to 4 business days. Please make sure to leave your name and call back number in case we need to contact you back. 

If you request a vaccine record or a form to be completed that needs to be expidited there is a $25 fee for a 24 hour (1 business day) turn around. 

• MCHAT (18 mos)
• GAD-7 (10-11 yrs +)
• PHQ-9 (10-11 yrs +)

Please call (713) 932-6261 Ext: 208 for vaccine record requests. If your child’s account has been web-enabled, you may access vaccine records there:  Great Kids Pediatrics Patient Portal

If you request a vaccine record or a form to be completed that needs to be expidited there is a $25 fee for a 24 hour (1 business day) turn around. 

Please use this form to request records from our office. Please return this form to: gkpbilling1@gmail.com