New Patient Packet
Please complete all documents for your child. (If you are bringing multiple children to Dr. Adams, be sure to include their names on the first 4 pages of the packet.)

Additional Child Packet
Please complete one packet for each child in addition to your first child.

HIPAA Notice of Privacy Practices
This document states the HIPAA privacy policy of Adams Pediatrics. It is NOT necessary to print this form. Copies are also available at the office.

Preparticipation Physical Education – Medical History
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in activities.

Form to Release Medical Records

Form to release medical records TO Adams Pediatrics
If you would like your child’s complete medical record to be transferred to Adams Pediatrics, you may print this form, sign it, and bring it to your appointment.(You will need to complete one form for each child.) We will then send your request to your former doctor.

Form to release medical records FROM Adams Pediatrics
If you may are requesting your child’s complete medical record from Adams Pediatrics, you may print out this form, sign it, and bring or send it to Adams Pediatrics. (One form for each child, please.)

Please note that we will release medical records at no charge if they are to be sent directly to another provider. Medical records released to any other person or entity will be charged according to the rulings set forth by the Texas State Board of Medical Examiners. If you would like to receive a copy of the medical records in .PDF format, be sure to include your email address on the request. If you would like to receive a printed version of the record, the cost will be $5.00 for the first 20 pages, and $0.25 per page for each page after 20, plus postage.

ADHD Forms

NICHQ Vanderbilt Assessment Scale – Parent Informant
A diagnostic tool to be completed by the parent and turned in to the doctor for use in determining whether the child has ADHD.

NICHQ Vanderbilt Assessment Scale – Teacher Informant
A diagnostic tool to be completed by the teacher and turned in to the doctor for use in determining whether the child has ADHD.