We are excited that you have chosen Proyouth Pediatric Health & Wellness for your child's medical care. Your comfort and convenience are our priority, and we strive to make every visit to our office a positive experience. To help you get acquainted with our office and first visit procedures, we have included helpful information on this page.

Our Mission

Our practice is working together to build life-long relationships between our staff and our patients by consistently providing our patients with compassion, excellence and value. To fulfill this mission, we are committed to:

•  Improving the lives of the children we serve by providing quality care in a child-centered environment.
•  Listening to our young patients and their families who we are privileged to serve.
•  Guiding our patients along a path of optimal health and wellness.
•  Continually pursuing excellence at all levels through continuing education.

Patient Forms

To expedite your first appointment, please arrive a few minutes early to complete registration forms so that we have all the necessary information to treat your child. You may also download and print the forms from this website, fill them out ahead of time, and bring them with you to the first appointment.

•  New Patient Packet PDF Form
•  Health History PDF Form
•  AUTHORIZATION FOR RELEASE OF INFORMATION TO SCHOOLS & DAYCARES FORM
•  DISCHARGE POLICY FORM
•  FINANCIAL POLICY FORM
•  HEALTH FORM POLICIES FORM
•  NON-COVERED AGREEMENT FORM
•  PATIENT’S RIGHTS AND RESPONSIBILITIES FORM
•  NON-COVERED AGREEMENT FORM
•  PHOTOGRAPHY CONSENT FORM
•  AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FORM
•  DECLINE OR START SHARING/INFORMATION REQUEST FORM
•  REGISTRATION FORM
•  HEALTH HISTORY FORM
•  PATIENT HEALTH QUESTIONNAIRE (PHQ9P)
•  SCHOOL ENTRY PHYSICAL FORM
•  PHYSICIAN'S REPORT-CHILD CARE CENTERS FORM (CHILD'S PRE-ADMISSION HEALTH EVALUATION)
•  PRE-PARTICIPATION PHYSICAL EVALUATION FORM
•  POSTPARTUM SCREEN EPDS FORM
•  OFFICE POLICIES FORM
•  MONITORING YOUR CHILD'S ATTENTION DEFICIT DISORDER FORM
•  MEDICATION POLICY FORM FORM
•  CHILD-SCAT3 FORM (Sport Concussion Assessment Tool for children ages 5 to 12 years)
•  HIPPA NOTICE OF PRIVACY PRACTICES FORM
•  NON-COVERED AGREEMENT FORM
•  Policy on Divorce, Separation, & Custody Agreements Form
•  Asthma Action Plan Form
•  Food Allergy and Anaphylaxis Emergency Care Plan Form
•  Childhood Asthma Control Test for children 4 to 11 years old Form
•  CHILD-SCAT3 FORM (Concussion Initial Evaluation 12 years and younger)
•  Appointments Phones Insurance Referrals Prescriptions Form
•  ADHD Follow Up Visits Form
•  SCAT3 FORM (Concussion Initial Evaluation 13 years and older)

In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.

What to expect

On the day of your child's first visit to our office, we recommend arriving a few minutes early. This allows extra time for finishing up any registration forms and ensures you have plenty of time to get acquainted with our staff and office. We look forward to meeting you and joining with you to help your child maintain optimal health.

To help expedite the first appointment, we ask that you please bring your child's immunization records and insurance card. Be prepared to complete paperwork regarding your family medical history, your child's medical history, and insurance information.

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