Patient Forms


These completed and signed forms are required prior to starting a telemedicine visit.

Telemedicine Consent Form

Telemedicine Advanced Beneficiary Form

Telemedicine Instruction Handout

New Patients

Please feel free to download, print, and fill out the following forms prior to your appointment.  Bring these forms to your initial visit or to update your records to expedite your check-in.  The forms below are copyrighted and may not be used (in whole or in part) for purposes other than for completing forms for Pecan Tree Pediatrics.


All Patients

At any time, you may read and download a copy of our Privacy Practices.  A copy of this document will be provided to you at our office at any time upon request.

Attention Deficit Disorder (ADD / ADHD) Visits

Prior to your child’s appointment for an evaluation of or follow up of ADHD / attention and focus issues, please complete the following forms.  If your child has more than one teacher, please print the number of forms needed so that each teacher can complete his or her own form.

For new assessments / evaluations, please complete forms and return PRIOR to your appointment.

For follow up appointments, return these completed forms to the office before or at the time of your appointment.

Sick Visits

So that we can better address your concerns at your child’s sick visit, we have a form to help us understand the symptoms your child is experiencing. You may download, print, and complete this form prior to your visit.

Medical Release

Please allow 5 business days to complete your request for Medical Records.


Vaccine Refusal

At Pecan Tree Pediatrics, we advocate and encourage fully immunizing your child on the schedule recommended by the Centers for Disease Control.  However, in the case your family chooses to not vaccinate in a timely manner or at all, we require a Refusal to Vaccinate Form to be signed by the child’s parent or guardian.