Welcome to the "Forms and Email" area of the web site. From this page
you can access some of the forms that we have our patients fill out so you can
get them ready now, saving time when you come to the office for your
appointment. This section also allows you to send us email through the
website to request an appointment, medication refill, or specialist referral, to give us feedback on
the website, or to contact the webmaster about a problem. You can also
sign up to be notified by email when we receive our flu shots each
fall or to be notified whenever we add
something to our site. Please note, because of a huge volume of
spam, we do not accept any email that has not been entered into one of the forms
on this site.
Before
using any of the email functions, please read our Email
Disclaimer.
Click on the appropriate section:
Forms for New Patients:
Thank you for deciding to join the Catalina Pediatrics family. We hope
you will find your relationship with us rewarding. Before you move on, please check with our office to see if
we are accepting new patients.
Each link below takes you directly to a form that you can fill out
(use the "tab" key to move between fields) and print. None of
the information you enter will be sent to us or to anyone else on the
internet. It will remain on your computer only, so please make sure you
print or save the form before moving on, otherwise you will lose what you have
entered. You can also print the form without entering any information and
then fill it in by hand if you prefer.
 | New Patient
Questionnaire - This form contains medical information we need to
collect for all new patients. |
| Privacy Notice - As of April 14, 2003 it is federal law (called HIPAA) that we give
you a notice of your privacy rights and the policies of how Catalina
Pediatrics will use your health information before we provide you with medical care
(except in cases of emergency). First, please review the notice (there's also a printer-friendly
version) and then go to the next step below. |
| Patient Registration Form - This form includes your address, insurance
information, and other important demographic information we need. It
also contains your acknowledgment of the Privacy
Notice listed above.
Please make sure you sign it at the bottom after printing it out. We must have this form signed and on file
before your child can be seen for an appointment. |
Forms for Established Patients:
Each link below takes you directly to a form that you can fill out
(use the "tab" key to move between fields) and print. None of
the information you enter will be sent to us or to anyone else on the
internet. It will remain on your computer only, so please make sure you
print or save the form before moving on, otherwise you will lose what you have
entered. You can also print the form without entering any information and
then fill it in by hand if you prefer.
| Privacy Notice - As of April 14, 2003 it is federal law (called HIPAA) that we give
you a notice of your privacy rights and the policies of how Catalina
Pediatrics will use your health information before we provide you with medical care
(except in cases of emergency). If you have not been to our office
since April 14, 2003 and have not signed a form indicating that you have
been given a chance to review our privacy notice, please review it now (there's also a printer-friendly
version) and then go to the next step below. |
| Patient Registration Form -
Use this form to update your address, insurance
information, or other demographic information. It also contains your
acknowledgment of the Privacy Notice
listed above. Please make sure you sign it at the bottom after printing it out.
Even if none of your information has changed, if it has been more than a
year since we last had you fill out this form, we may request that you fill
out a new one at your next appointment.
|
Date this page was last changed:
10/28/2007
|
