Patient Forms

We have forms available online for you to view and print. Completing necessary paperwork prior to your child’s visit helps quicken the check-in process. Please take a minute to complete all applicable areas on the form prior to dropping it off or emailing it to our office.

Forms Packets

• Newborn Paperwork (New Patient)
• New Patient Registration Paperwork

Individual Forms

• COVID Vaccine Consent Form, Pfizer EUA 
• Telemedicine Consultation Form
• Family History Form (Yearly Update)
• Prenatal Forms
• Authorization for Treatment (In absence of Parents/Guardians)
• HIPAA rev 11/1/2017
• Financial Policy

School, Camp & Daycare Forms

Pediatric Associates of Alexandria has made our school, camp, and daycare forms an entirely electronic process for our patients. We will no longer accept forms dropped off, emailed, mailed, or faxed to the office. We encourage you to bring any form(s) needed to your child’s well check appointment which will be done for free at that time.

Pediatric Associates of Alexandria ha hecho que nuestros formularios de escuela, campamento y guardería sean un proceso completamente electrónico para nuestros pacientes. Ya no aceptaremos formularios entregados, enviados por correo electrónico, por correo postal o por fax a la oficina. Lo alentamos a que traiga los formularios necesarios a la cita de control de bienestar de su hijo, que se realizará de forma gratuita en ese momento.

Effective 09/15/2022, we will no longer accept forms that are emailed, dropped off, or faxed to the office.

Access Online Forms

Additional Forms

• Forms for Dr. Shropshire's Patients - Developmental Pediatrician
• Screening Forms - Vanderbilt ADHD Forms, Scared Patient AKG (Anxiety Related Disorders), M-Chat R/F (Autism), Behavioral Health forms for Therapy, PHQ9 (Depression)
• Medical Records Release
• Specialists Referrals
• Parent Survey