CPM encourages all patients to print and complete the forms prior to their visit. Please arrive 15 minutes before your appointment; this time will be used to complete any additional forms that are not posted on our website. You may also take this time to ask any further questions in regards to your appointment.
- Welcome to Center for Pediatric Medicine Brochure
- Patient Registration Form
- Patient Registration: Spanish
- Patient Registration: Portuguese
- Confidential Communication Authorization
- Confidential Communication Authorization: Spanish
- Signature of Notice of Privacy Practices
- Signature of Notice of Privacy Practices: Spanish
Health Care Assessments
Health Care Screenings
- Designation of Authorized Representative
- Change of Information Form
- 18 Year Old PHI Release Form
- PHI Release Form
- Authorization for Release of Health Information:Transfer of Patient Records-Into the Practice
- Authorization for Release of Health Information:Transfer of Patient Records -Out of the Practice
M-CHAT QUESTIONNAIRE (Autism Screening)
M-Chat (the Modified Checklist for Autism in Toddlers) is a list of 23 questions used to screen toddlers for autism at their 18 and 24 month physical exams. Please click here for a printable copy of the questionnaire, which you can complete and bring with you at the 18 and 24 month appointments.
Fluoride test kit Information It is important to have your well water tested for fluoride content. Fluoride is naturally occurring in groundwater and therefore may be in your well water in trace amounts, adequate amounts or even excessive amounts than the recommended level. It is wrong to assume that well water has no fluoride. The best way to be sure your child is receiving the appropriate amount of systemic fluoride is to have your well water tested for fluoride content. Please click here for the UConn fluoride testing information sheet.