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Mother and Baby on Floor

Forms

Below you will find some forms you may need during your time with our office. To submit a form, please download it, either complete online or print out and complete manually, and return the form to our office via mail, fax, our office email (algerped@algerpediatrics.com), or in person.

 

These forms are also available at our office. Please stop by at any time during our open hours to request them.

18+ registry update

Please submit your updated address and contact information to our office once you turn 18.

covid consent form (over 12)

Please bring this completed form to your appointment for the first COVID vaccine.

information disclosure form

Please submit this form to share medical information with another party, such as a parent or guardian.

sports physical form

Please complete the health history portion of this form and return it to our office to be signed by a doctor/nurse.

covid consent form (under 12)

Please bring this completed form to your appointment for the first COVID vaccine.

INFLUENZA FORM

Please bring this completed form to your appointment for the flu vaccine.

Records release form

To have your records transferred to a different office or sent directly to you, please complete and submit this form.

Disclosures

Below you will find our office notices and disclosures. They are also available at our office. Please stop by at any time during our open hours to request a copy.

notice of privacy practices

Below you will find the notice of privacy practices statement for our office.

non-discrimination policy

Below you will find the non-discrimination statement for our office.

patient centered medical home

Below you will find the patient centered medical home statement for our office.

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