Patient Forms

Before your appointment with us, quickly and conveniently access patient forms from our practice.

We will do our best to process new patient requests within 5 business days. We receive an extremely large number of new patient requests each day, but new patient requests will be processed as quickly as possible. If you are not contacted within 2 calendar weeks, please contact our office by phone, at (541) 567-6434 ext 207.

Please be aware that previous medical records will be required to assure that we can provide for your medical needs. Please request your previous records by filling out an ROI, Release of Information form and giving it to your previous provider.

To view the forms listed below, you will need to download Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.

Pediatric Development Screening Forms

When preparing for your child’s next well child visit, please select and print the age-appropriate form from the list below, fill it out completely, and bring the form with you to your child’s appointment.

Child’s AgeEnglishSpanish
1 Month1 month
2 Months2 months2 months
4 Months4 months4 months
6 Months6 months6 months
9 Months9 months9 months
12 Months12 months12 months
15 Months15 months15 months
18 Months18 months + M-CHAT18 months + M-CHAT
2 Years24 months + M-CHAT24 months + M-CHAT
2 1/2 Years30 months30 months
3 Years3 years3 years
4 Years4 years4 years
5 Years5 years5 years
6-10 Years6-10 years
11-12 Years11-12 years
13-17 Years13-17 years
18-21 Years18-21 years