Forms need downloaded, printed, and signed. Signatures must be actual and not electronically generated.

Note: Some of the following forms are in PDF format.

If you have problems with viewing them, please click below to download Adobe Acrobat (PDF) Reader.

Influenza Vaccine Consent Forms

Parents: Please fill out and bring this form to the office when getting your flu shot.

Transfer Forms

Transferring from another practice

• Request form for Medical Records to be transferred to Village Pediatrics

New Patient Forms

Please print, fill out, sign, and bring to first visit (All Patients!)

• New Patient Registration Form
• Medical History Questionnaire
• (New) Financial Policy Form with Authorization form
• (New) Common Questions about Added Benefits

Required State Health Forms

• State of CT Department of Education - Health Assessment Record form
  (This form MUST be printed on BLUE paper!)
• State of CT - Early Childhood Health Assessment Record form

Assessment Tools for Parents

• SNAP - Teacher and Parent Rating Scale
• MCHAT - Modified Checklist for Autism in Toddlers
• PSC - Pediatric Symptoms Checklist form
• New Mother Post-Partum Depression Evaluation

Teen Screening

• 16-22 years
• 12-15 years
• Parent Questionnaire

Exercise & Nutrition Assessment

• Personal Profile of Exercise and Nutrition (Fill out online and print)