Prepare For Your Visit
Before your appointment with us, quickly and conveniently access patient forms from our practice.
To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com.
Please bring your completed forms with you to our office at the time of your visit, or upload them to the Patient Portal.
Also, please bring any school/physical forms that need to be completed for your child’s school/sports at the time of your well visit. Forms submitted after the visit are subject to a $10.00 charge .
Download Patient Forms:
- Patient ID Form
- Patient ID Form 18 Plus
- Referral Request Form
- Patient Portal Request Form
- Patient Portal Request Form 18 Plus
- Record Release Authorization – Incoming
- Record Release Authorization – Outgoing
- Universal Child Health Record
- Asthma Treatment Plan – Student
Download Age-Appropriate Well Visit Forms:
Based on age, there may be more than one form to download and fill out.
Newborn Form (EPDS):
18, 24, and 30 Month Form (MCHAT):
2 Month to 5 Year Forms (SWYC):
- SWYC 2 Month Form
- SWYC 4 Month Form
- SWYC 6 Month Form
- SWYC 9 Month Form
- SWYC 12 Month Form
- SWYC 15 Month Form
- SWYC 18 Month Form
- SWYC 24 Month Form
- SWYC 30 Month Form
- SWYC 36 Month Form
- SWYC 48 Month Form
- SWYC 60 Month Form
6 Year to 10 Year Form (PSC):
11 Year to 17 Year Form to be Completed by the Patient (PSC-Y):
12 Year and Older Form to be Completed by the Patient (CRAFFT):
18 Year and Older Form to be Completed by the Patient (PHQ-9):
Silverton Pediatrics and PCMH:
A patient-centered medical home (PCMH) means that you and your child will be surrounded by a dedicated team of health professionals; working together with you to optimize your child’s health goals using the best evidenced-based medicine, education, and resources available for your family today, thus helping empower you to take responsibility for your child’s health and give you the self-management support you need to succeed.
As your child’s primary care provider, we will:
- Learn about your child, your family, life situation, health goals and preferences. Our team will recall your health history every time you seek care and will suggest treatments that make sense for your family.
- Take care of any short-term illness, long-term chronic disease, and your child’s all around well-being.
- Keep your child up-to-date on all vaccines and preventative screening tests.
- Connect your child with members of their care teams (specialists, health-coaches, etc.) and coordinate care with them as your child’s health needs change.
- Notify you of test results in a timely manner.
- Communicate clearly so that all conditions and options are well-understood.
- Listen to your questions and feelings. We will respond promptly to you, and your calls, in a way you understand.
- Help you make the best decision for your child’s care.
- Give you information about classes, support groups, or other services that can help you learn more about your child’s condition and stay healthy.
We trust you as our patient to:
- Know that you are a full partner with us in your child’s care.
- When you join our practice you will provide us with a complete medical history and inform us if you obtained interim care outside the practice.
- Come to each visit with updates on medications, dietary supplements, or remedies you are using and any questions you may have.
- Understand your child’s health condition and what you can do to keep him or her as healthy as possible.
- Work with us to develop and follow a plan that is best for your child’s health. If you have obstacles in fulfilling this plan, please discuss them filly with our staff.
- Take medications as prescribed.
- Take advantage of our weekend hours and weekday same-day appointment options as necessary to avoid unnecessary ER and urgent care visits that may be more expensive and fragment care.
- Agree that all health care providers in our practice can share and collaborate on information related to your child’s healthcare.
