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Pediatric and Young Adult Medicine

Pediatric and Young Adult Medicine

Welcome to our Tradition of Caring

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Forms

Save time! Here are several Medical Forms for you to fill out before your visit.

In order to provide optimum healthcare, we ask that you complete medical paperwork before your visit. Completing these forms before your visit saves time at the Center and allows you privacy and access to information.

Please download, print single sided and fill out the forms below and bring them with you to your visit. Fill out the forms in black or blue ink only and check or cross the boxes off individually.

To view these files you will need to have Adobe’s Acrobat Reader.
Its a free download and is available for both the Mac and Windows.

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Patient ADHD Refill Instructions 87.42 KB 69 downloads

Use this checklist to collect the information you need before you call in and make...
Download
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Wart Treatment 158.93 KB 40 downloads

Wart Treatment ...
Download
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Wart Consent 55.91 KB 28 downloads

Wart Consent ...
Download
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Release of Information Form 115.51 KB 756 downloads

Release of Information Form for all PYAM patients. ...
Download
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New Patient Package 1.65 MB 136 downloads

New Patient Package ...
Download
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Flu Screening Questionnaire 76.90 KB 34 downloads

Flu Screening Questionnaire ...
Download
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Asthma Control Test for Children 4 to 11 years 383.38 KB 27 downloads

Asthma Control Test for Children 4 to 11 years ...
Download
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Asthma Control Test for Patients 12 Years or Older 161.24 KB 30 downloads

Asthma Control Test for Patients 12 Years or Older ...
Download
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Bright Futures Previsit Questionnaire 342.40 KB 54 downloads

Bright Futures Previsit Questionnaire ...
Download
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Authorization for Treatment of a Minor 59.12 KB 74 downloads

Authorization for TreatmentAuthorization for Treatment of a Minor ...
Download
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Pediatric & Young Adult Medicine

• Maplewood
• Woodbury/Lake Elmo
• St. Paul
• Eagan
• Hudson
For appointments only please call 651-256-6714.
To speak with a provider & for all other purposes please call 651-227-7806 (MN) or 715-386-6800 (WI).

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