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To scan and return completed forms, download Adobe Scan if you do not have a scanner
and you can scan and return with your phone (scan QR code to install directly onto your phone)
New Patient Forms
Privacy Acknowledgment- For children under 18
Consent for Treatment- For children under 18
Financial Policy Acknowledgement- For children under 18
NH Vaccine Registry Opt-in/out Form
Authorization Forms
Verbal Authorization form- For patients under 18, to be filled out by parent or guardian who authorizes Concord Pediatrics to speak with someone other than a parent or guardian.
Consent for Non-Parent to Bring a Minor Child to Appointments
Consent for Minor Child to Attend Appointments without Parent/Guardian
Authorization for Patients 18 and older- Access for parents
Consent for treatment- 18 years and older- When patients turn 18 they are legally responsible for themselves and authorizing Concord Pediatrics to provide medical care
Privacy Acknowledgement- 18 years and older- When patients turn 18 they Concord Pediatrics has the responsibility of informing them of our Privacy Practices
Financial Policy Acknowledgment- 18 years and older- When patients turn 18 they are legally responsible and must acknowledge the financial responsibility at Concord Pediatrics; If the patient is on their parent's insurance, the parent can remain the guarantor
Attention Deficit Hyperactivity Disorder (ADHD) Forms
NICHQ Vanderbilt Assessment Forms are one tool we use to diagnose Attention Deficit Hyperactivity Disorder. If you have concerns about your child and ADHD, please discuss those concerns with one of our medical providers prior to using these forms.
If your child's medical provider has directed you to fill out the NICHQ Vanderbilt Assessment Scale and to distribute them to your child's teacher(s), please use the links below to access a printable copy.
- NICHQ Vanderbilt Assessment Scale - Parent Forms
- NICHQ Vanderbilt Assessment Scale - Teacher Forms
- NICHQ Vanderbilt Assessment Follow-up - Parent Forms
- NICHQ Vanderbilt Assessment Follow-up - Teacher Forms
The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist is designed to be filled out by an older teen or adult on their own. The form is designed to stimulate dialogue between a teen or adult patient and his or her medical provider and to help confirm if they may be suffering from the symptoms of attention-deficit/hyperactivity disorder (ADHD).
Food Allergy and Anaphylaxis Emergency Care Plan
Please print out and complete the form below and bring it to the office to be signed. (Please allow 24 hours for our providers to review and complete the form.)
- Food Allergy and Anaphylaxis Emergency Care Plan [Edited by Concord Pediatrics, P.A.]
- Original form from Food Allergy Research and Education (FARE) available here.
- Anaphylaxis Emergency Action Plan [from American Academy of Allergy Asthma & Immunology]
Asthma Action Plan