Forms
We want to make your experience at South River Pediatrics as smooth and efficient as possible. To save time in the waiting room, please complete all pertinent forms before your child's appointment. Please fill out one packet per child. These forms are critical to your child's care and enable us to provide the best possible service. Thank you in advance for taking the time to fill out these forms.
New Patient
At South River Pediatrics, we know that every child is unique. That's why we take the time to get to know you and your child, so we can provide personalized care. As a new patient, you can expect a warm welcome from our team and a thorough physical exam of your child. We will also discuss your child's medical history and answer any questions or concerns you may have. We are committed to providing your child with the best care possible.
Individual Forms
To make things easier for our patients, South River Pediatrics has created a list of individual forms that may be required for your child's appointment. You can easily access the forms online by clicking on the links below. Please be sure to complete all forms prior to your appointment to ensure that we can provide the best care for your child.
Newborns Only
Congratulations on your new bundle of joy! At South River Pediatrics, we are committed to providing the best newborn care to ensure your baby's health and development. We strive to establish a lasting relationship with your child and your family, and make sure you have all the resources and support you need to navigate this exciting new chapter in your life. This form is for insurance purposes stating the patient will have insurance after 30 days, otherwise it is the parent/guardian's responsibility.
Medical Records
If you are moving away or transferring, please complete the following form and submit the form via fax at 410-956-6637, email the completed form to medicalrecords@srpeds.com, or drop the form off at any location.
Please specify which records you'd like, whether the complete chart, between a certain time frame, and/or lab work, etc. If you'd like to follow up on the status of your request, call our Edgewater office and follow the prompt to the Records Department.
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.
Patient Health Questionnaire (PHQ-9)
(Modified for Teens)
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 (Parent)
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 Information)
NICHQ Vanderbilt Assessment Scale
(Parent Information)
Telemedicine Services Agreement Form
The purpose of this agreement is to provide patients/families with information about South River Pediatrics' Telemedicine Services and to inform you of what you are consenting to during the visit.