Patient Forms

We ask all our families to complete a new Patient Registration Packet every two years so that we can be sure we have the most up-to-date information to better serve you. 

Please print out the following forms, complete the necessary sections requiring information or a signature and bring them to your first appointment to the office.

Please note some of the following forms are regarding our office policies and require no completion. These are for your information only.

Patient Registration Forms (For Patients 17 years of age and Under)

** Starred forms are for your information only and do not need to be completed.

Patient Registration Forms (For Patients 18 years of age and Over)

Please have the Patient complete and sign these forms.

** Starred forms are for your information only and do not need to be completed.

Alternative Caregiver Consent Form

In order to designate another adult to bring your child into our office for medical care in your absence, you must complete and sign an Alternative Caregiver Consent Form. Except for life-threatening emergencies, we are not able to treat your minor child unless he or she is accompanied to our office by a parent, legal guardian or a responsible adult designated on this form.

Release of Medical Records FROM Glendale Pediatrics

You may use this form to request a copy of your child's medical records to be picked up from our office. Please be aware that there is a fee for duplication of medical records per patient. An additional fee will be charged if the chart is exceptionally large or if you request that the records be mailed. Please be advised that we do not fax medical records. Records will be provided to you within 15 business days from the date that Glendale Pediatrics receives your written request.

Release of Medical Records TO Glendale Pediatrics

This form can be used to request a copy for your child's medical records from your previous pediatrician or specialist. Please complete and sign the form and give directly to your child's prior physician(s).

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

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Please call our office at (818) 246-7260

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