Forms & Policies | Post Road Pediatrics

  • New patient registration packet
    To become a new patient, please complete and return our new patient registration packet
  • Medical release authorization form
    If you would like for us to communicate with another medical or behavioral health provider, school staff, or anyone else involved in your child's care, please complete the medical release form
  • Medical release authorization form for patients 18+
    If you are 18 years of age or older, we need your written permission to communicate with your parents. Please use this form to indicate whether or not Post Road Pediatrics has your permission to do so.
  • MyChart consent for patients 18+
    If you are 18 years of age or older, you are able to give your parents access to your MyChart portal by completing this form.
  • Medical record transfer form / psychotherapy record transfer form
    If you are requesting copies of your medical record for transferring out of our practice, or for your own record, or to provide to another physician/provider, please complete a record transfer form. If psychotherapy notes are being requested, please also fill out the psychotherapy record release form.
  • Alternate caregiver form
    If you would like someone other than a parent/legal guardian to bring your child to medical appointments, please complete the alternate care giver form.
  • Notice of privacy practices