Forms

• Patient Registration Form
• Authorization for Release of Medical Records
• Insurance Claim Submission Form
• E-Mail Waiver Form
• Privacy Practice Notice Acknowledgement
• PCMH Brochure
• Refusal to Vaccinate
• Sliding Fee Application
• Sliding Fee Policy

• ADHD Parent Initial Form
• ADHD Parent Follow-Up Form
• ADHD Teacher Initial Form
• ADHD Teacher Follow-Up Form

We utilize CHADIS, an online screening tool, for the majority of our screens in the office. We prefer to e-mail an invitation for you to complete these screens from home via CHADIS. However, you may print and complete the appropriate screen in advance of your appointment on paper if preferred.

• CHADIS (Child Health and Development Interactive System)
• Edinburgh Postnatal Depression Scale
• GAD-7
• MCHAT
• PHQ-9 (Adult)
• PSC-17
• SCARED Anxiety Screen (child to complete)
• SCARED Anxiety Screen (parents to complete)
• CRAFFT Adolescent Assessment Form

• Georgetown County Athletic Pre-Participation Form
• Formulario de Preparticipación Atlética del Condado de Georgetown
• Horry County Athletic Pre-Participation Form
• SCISA Form

• Riverside Pediatrics Patient Registration Form
• Authorization for Release of Information
• Automatic Insurance Claim Submission