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South River Pediatrics

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New Patient Forms

Save time in the waiting room! Please complete all pertinent forms before your appointment. You must complete one packet per child. 

Individual Forms

If you need an individual form, please choose from the list below.

Newborns Only*

  • Newborn Waiver - Online: This is for insurance purposes stating the patient will have insurance after 30 days, otherwise it is the parent/guardian's responsibility.

Physical Forms

The forms below require your child(ren) to have a physical/well check-up within the year in order for our medical staff to complete. Please be sure to call the front desk and ensure that your child is up-to-date and have the "History" section completed before submitting to our office. 

If your child's sport requires a physical within six months, we may be able to accommodate as a sports clearance visit.

School Medication Forms

Please complete the top portion of the appropriate form with the exact name of the medication. The form must specify whether brand or generic.

Special Forms

The Patient Health Questionnaire (PHQ-9) is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. The PHQ-9 incorporates DSM-IV depression diagnostic criteria with other leading major depressive symptoms into a brief self-report tool.

Screen for Child Anxiety Related Disorders (SCARED) is required for any patient scheduled for an Anxiety/Depression Consult. One is to be completed by the parent/guardian and one is to be completed by the child.

NICHQ Vanderbilt Assessment Scale is required for any patient scheduled for an A.D.D./A.D.H.D. consult. One is to be completed by the teacher and one is to be completed by the parent/guardian.

The Connors Evaluation is required for any patient scheduled for an A.D.D./A.D.H.D. consult. One is to be completed for every teacher and the parent/guardian.

Telemedicine Services Agreement Form: The purpose of this agreement is to provide patients/families with information about South River Pediatrics’s Telemedicine Services and to inform you of what you are consenting to during the visit.

Medical Records

If you are moving away or transferring, please complete the following form and submit the form via fax at 410-956-6637, email the completed form to medicalrecords@srpeds.com, or drop the form off at any location.

Please specify which records you'd like, whether the complete chart, between a certain time frame, and/or lab work, etc. If you'd like to follow up on the status of your request, call our Edgewater office and follow the prompt to the Records Department.