New Patient Forms
Save time in the waiting room! Please download, print, and complete all pertinent forms before your appointment.
- New Patient Forms Packet (10 pages)
If you need an individual form, please choose from the list below.
- Newborn Waiver: This is for insurance purposes stating the patient will have insurance after 30 days, otherwise it is the parent/guardian's responsibility.
The forms below require your child(ren) to have a physical/well check-up within the year in order for our medical staff to complete. Please be sure to call the front desk and ensure that your child is up-to-date and have the "History" section completed before submitting to our office.
If your child's sport requires a physical within six months, we may be able to accommodate as a sports clearance visit.
- Lead Testing Form
- Sports Physical Forms (Version 1)
- Sports Physical Forms (Version 2)
- Health Inventory
School Medication Forms
Please complete the top portion of the appropriate form with the exact name of the medication. The form must specify whether brand or generic.
- Calvert County Public School Request Form to Administer Medicine
- Anne Arundel Country Schools Request Form to Administer Medication
The Patient Health Questionnaire (PHQ-9) is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. The PHQ-9 incorporates DSM-IV depression diagnostic criteria with other leading major depressive symptoms into a brief self-report tool.
Screen for Child Anxiety Related Disorders (SCARED) is required for any patient scheduled for an Anxiety/Depression Consult. One is to be completed by the parent/guardian and one is to be completed by the child.
- Screen for Child Anxiety Related Disorders (SCARED) - Parent
- Screen for Child Anxiety Related Disorders (SCARED) - Child
NICHQ Vanderbilt Assessment Scale is required for any patient scheduled for an A.D.D./A.D.H.D. consult. One is to be completed by the teacher and one is to be completed by the parent/guardian.
- NICHQ Vanderbilt Assessment Scale - Teacher Informant
- NICHQ Vanderbilt Assessment Scale - Parent Informant
The Connors Evaluation is required for any patient scheduled for an A.D.D./A.D.H.D. consult. One is to be completed for every teacher and the parent/guardian.
Telemedicine Services Agreement Form: The purpose of this agreement is to provide patients/families with information about South River Pediatrics’s Telemedicine Services and to inform you of what you are consenting to during the visit.