Forms

All the forms shown below may be printed directly on your computer system. Additionally, if there is an asterisk (*) alongside the form name, information can be electronically entered directly onto that form, and then printed. Please see the instructions below.

These forms are supplied in Adobe® PDF format. You will need to have the Adobe Acrobat Reader installed on your system to view and or print them. If you don’t have this software, you can download it from Adobe at no charge.

Click here to view other forms that you can print out and complete before your visit.

Registration Forms
Form #	Form Name	Use
1	Patient Registration *	Registration information for new patients coming into our practice.
2	Medical History Form	Lists your family’s health and medical history.
3	Financial Policy (Note: 2 pages)	This form explains and documents the financial relationship and agreement between you and Lake Shore Pediatrics.

Other Forms
Form #	Form Name	Use
1	Medical Records Release Form *	Enables us to send or obtain a patient’s medical records to or from a third party (doctor, etc.)
2	Authorization for Treatment *	Authorizes individuals other than parents or guardians (i.e. grandparents, friends, nannies, etc.) to bring listed children to a Lake Shore Pediatrics office for treatment.

Step 1: How to select a form
Double click on the appropriate form name shown above. The form will then be loaded and displayed within this display area using Acrobat Reader.

If you’d like to hand print or type using a typewriter the requested information on the form, go to Step 3.

Step 2: How to enter information directly on a form
If an asterisk (*) appears alongside the form name in the list above, it means this form may also be filled out electronically by entering the information directly on your PC, and then printing the form.

To enter information, position the cursor with your mouse on the field you want to enter and then left-mouse-click, or tab to it using the keyboard TAB key.

Step 3: How to print a form
Once a form has been displayed by Acrobat Reader, left-mouse-click the printer icon contained in the upper left hand corner of the Acrobat Reader window area (directly underneath the yellow “New Patients” menu.) to print it on your PC’s printer.

Step 4: Sign the Form (if required), then mail, fax or bring it to the Lake Shore Pediatrics office that you visit