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South River Pediatrics

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New Patient Forms

Save time in the waiting room! Please download, print, and complete all pertinent forms before to your appointment. You may fax them to our office or bring them with you to your appointment.

Individual Forms

If you need an individual form, please choose from the list below.

Newborns Only*

  • Newborn Waiver: This is for insurance purposes stating the patient will have insurance after 30 days, otherwise it is the parent/guardian's responsibility.

Physical Forms

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(such as with football), we may be able to accommodate as a sports clearance visit.

School Medication Forms

Please complete the top portion of the appropriate form and the exact name of the medication. The form must specify whether brand or generic.

Special Forms

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 parents/guardians.