New Patients

Welcome to Chapin Pediatrics!

We consider it an honor and privilege to be chosen to serve as the healthcare provider for your child. If you are a new patient that has received confirmation from us to join our family you will find the forms below helpful. Filling out the forms prior to your first visit and bringing them with you will assist in the new patient processing.

If you have any questions about these forms or anything in general, please do not hesitate to contact our office. If you are on social media sites, please make it a point to follow us/like us as we attempt to use all means possible to communicate and keep you informed.

Again, we thank you for the privilege to serve you.

New Patient Forms

Patient Demographic Form PDF (updated: 2018 September)
Financial Policy PDF (updated: 2018 September)
Authorization Form – HIPAA PDF (updated: 2018 September)
Records Request-Release PDF (updated: 2018 September)
Authorization to Treat a Minor Patient in Absence of Parent or Guardian PDF (updated: 2018 September)
Notice of Privacy Practices – HIPAA PDF (updated: 2018 September)
Receipt of Privacy Notice – HIPAA PDF (updated: 2018 September)