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  1. Wakefield Pediatrics
  2. Resources
  3. Forms

Wakefield Pediatrics Forms

  • Resources
    • Forms
    • Medical Home
    • Vaccinations
    • Web Resources
    • Tips for the Flu Season

Forms

  • Patient Information/Demographics
  • Authorization for Release of Medical Information
  • Authorization for Release of Medical Information (Over 18)
  • MyChart Consent Form
  • Insurance Waiver
  • Vaccine Management Patient Eligibility Screening

Policies

  • HIPPA/Privacy Practices
  • Acknowledgement of Receipt of HIPAA/Privacy Practices
  • No Show Policy
  • Behavioral Health No Show Policy

Tools

  • Headache Log
  • Headache Diary
  • Vanderbilt Assessment Scale – Teacher Rating Scale
  • Vanderbilt Assessment Scale – Parent Informant
  • Screen for Child Anxiety Related Disorders (SCARED) – CHILD Version
  • Screen for Child Anxiety Related Disorders (SCARED) – PARENT Version
  • Guided Self-Management Tools for ADHD
  • Guided Self-Management Tools for Anxiety (Child)
  • Guided Self-Management Tools for Anxiety (Teen)
  • Guided Self-Management Tools for Depression (Child)
  • Guided Self-Management Tools for Depression (Teen)
lobby of pediatric office
nurse taking a boy's height

Wakefield Pediatrics

15 Richardson Avenue
Wakefield, MA 01880

Phone: 781-245-2203
Fax: 781-245-7303

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