Forms

• Medical Records Release Form TO FWP (PDF)
• HIPAA (PDF)
• Demographics (PDF)
• Insurance Demographics (PDF)
• Insurance Helpful Hints (PDF)
• Patient Portal Registration (PDF)
• Financial-Policy

• Medical Records Release Form TO FWP (PDF)
• Medical Records Release Form FROM FWP (PDF)
• Patient Medical Consent Form (PDF)
• Financial Policy (PDF)
• Demographics (PDF)
• Insurance Demographics (PDF)
• Patient Portal Registration (PDF)
• Photo Release Form (PDF)
• 18+ Consent to Release Healthcare Information (PDF)

Parent Forms

• Vanderbilt Assessment Scale Initial Parent (PDF)
• Vanderbilt Assessment Scale Parent Follow-Up (PDF)

Teacher Forms

• Vanderbilt Assessment Scale Initial Teacher (PDF)
• Vanderbilt Assessment Scale Teacher Follow-Up (PDF)

• 2026-2027 IHSAA SPORTS PHYSICAL FORM (PDF)
• 2025-2026 IHSAA SPORTS PHYSICAL FORM (PDF)
• 2025-2026 OHSAA SPORTS PHYSICAL FORM (PDF)

Fort Wayne Pediatrics suggests that parents with minor children complete this:

• Consent to Treat Minor Form (PDF)

• MCHAT
• SCARED Anxiety Screen (parents to complete)
• Edinburgh Postnatal Depression Scale
• GAD-7
• SCARED Anxiety Screen (child to complete)
• PSC-17
• PHQ-9 (Modified for Teens)
• PHQ-9 (Adult)

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