Forms

We provide a range of useful information including new patient forms, general forms, policies, and more. To download any of these documents, simply click on the corresponding link below.

New Patient Forms

1. Acknowledgement of Receipt of Notice of Privacy Practices
2. Family Registration Form or Click here to download PDF Version
3. Consent to Treat
4. Financial Policy

General Forms

1. No Show Policy
2. Patient Health Questionnaire
3. M-Chat
4. Over 18 HIPPA Release Form

Transfer Forms

1. If you are joining Guardian Pediatrics, and you would like to request records from your previous practice: Download Release Form
2. If you are leaving Guardian Pediatrics, and you would like for us to send your child’s records to your new practice: Download Release Form

Policies

• Addition of Surprise Billing Notice – Federal
• Good Faith Estimate – In accordance with law, Guardian Pediatrics follows the guidelines set by House Bill 1447. If you would like to read House Bill 1447, please visit the Indiana General Assembly website. Or, you can click the following link to download our Good Faith Estimate.
• Notice of Privacy Policy
• Medication Refill Policy
  

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Daycare Form

Click the following link to download the state-issued daycare form that most daycares use. Download Daycare Form

IHSAA

Click the following link to download the pre-participation physical evaluation form (PPE) – download form.

NICHQ

NICHQ, National Institute for Children’s Health Quality, offers an assessment scale used in diagnosing ADHD. Click the following link to download the form – NICHQ Vanderbilt Assessment Scales

Vaccine Information

This download includes everything you need to know about your child’s first vaccines. To download the vaccine information, please click the following link. Download Your Child’s First Vaccine Information