Digital & Printable Patient Forms
Digital access to the forms you need before your child’s appointment.
We understand your time is valuable and you want to make the most of your child’s pediatric visit. For most visits, we do require updated paperwork before we can begin the appointment. Rather than spending your appointment filling out paperwork, you can now access patient forms online and fill them out before you leave!
If you’re unsure of what forms you need to fill out for your child’s next appointment, please visit our Well Child Visit Schedule page and select the appropriate visit or give our office a call at 262-569-7100.
Our Patient Forms
Review the forms below and either download the PDF, fill it out, and bring it to your appointment or complete the digital form and submit your information online beforehand.
ADD/ADHD, Depression/Anxiety Forms
To best care for your child with ADD/ADHD and/or Depression/Anxiety, we request that these forms be completed and returned prior to each visit to help us monitor his/her progress.
If your child is being treated for both ADD/ADHD and Depression/Anxiety, please complete the appropriate ADD/ADHD form and Depression/Anxiety forms below.
Medication Follow-up for Depression/Anxiety
Conners’ Global Index for ADD/ADHD
12 Years Old and Younger (CGI-P) 13 Years Old and Older (CGI-T)
Vanderbilt Assessment for ADD/ADHD (Dr Schilz patients)
Allergy Questionnaire / Consent for Allergy Testing
This form will help us learn important medical information about you and your family so we can focus our evaluation and testing appropriately.
Athletic Clearance Form
This form is generally provided by your child’s school, however, we do have the standard WIAA form should you need.
WIAA Form
Sports Questionnaire
Forms for New Patients
Whether you are new to the area, new to our practice, or a new parent, you’ll need to fill out a few new patient forms about your child. Either download and fill out the following forms and bring them into your first appointment or fill them out online and submit them electronically.
Demographics Form
Patient History Form & Privacy Notice
Patient Responsibility Form
Permission for Third Party to Seek Treatment
We want our office to be as convenient for you as possible, but we also require documentation to ensure your child’s safety and privacy.
This form is a guideline; you can modify if needed. We can put this in your child’s file, or you can leave it with your child’s temporary guardian in the event they need a visit.
Remember to leave instructions for your child’s regular medications, contact information for any places you may be staying, and a copy of your insurance card.
We especially recommend filling this form out if you are going to be out of town, if your parents or neighbors watch your children often, or if you have a nanny or regular caretaker.
We will need a separate form for each child. We will also request a copy of a photo ID from anyone who brings your child in; this will go in the child’s permanent file.
Permission for Third Party to Seek Treatment Form
General Consent for Admission/Treatment Form
This is the form for General Consent for Admission and Treatment.
General Consent for Admission and Treatment
Regular Well Child Visit Forms
Please review the Well Child Visit Schedule to review, complete, and digitally submit all appropriate forms for your child’s next visit.
Child Health Report
This form is generally provided by your child’s day care provider, however, we do have the standard State of Wisconsin form should you need.
Child Health Report Form
Release Medical Records
Please fill out the following forms either digitally or by printing and filling out prior to your first visit or when transferring care to another clinic.
Form to release previous medical records to or from Lake Country Pediatrics
Nominated and Awarded
Most Loved Pediatrician!
Dr. Moyer clinched the 1st place Top Pediatrician in Lake Country, Dr. Schilz made his mark in the top ten, and Dr. Kolp-Jurss made a stellar appearance in the top 15 – it’s a powerhouse of exceptional dedication!
