Forms

For your convenience, we have made several forms available for download.  This will have you better prepared for your visit and reduce the amount of forms you will have to fill out during your visit.  Just click on the links below to download a pdf copy of each form.

New Patient Packet

The new patient packet contains all the necessary information for becoming a new patient at Christie Pediatric Group.  It includes patient information sheet, billing information, medical record release form, GHS financial policy, consent for treatment, & disclosure of medical information. 

DHEC Form (Immunization Form)

A DHEC form (immunization form) should be filled out stating whether your child's immunizations are covered or not. If you have not filled this out before or you have had a change in insurance, be sure to fill out this form for your next visit.  This is a very important and necessary form to have on file for your child. 

Authorization for Release of Medical Information

If you need to have your child's medical records transferred from or to our office, you will need to fill out an authorization for release of medical information. 

Well Child Examination Vaccine Fees for Established Patients

This is a comprehensive listing of visits by age, the total fees billed to insurance and procedure codes billed. Useful for when contacting your insurance to verify what procedures are covered or not. This form is required at time of check in so it is best to call your insurance before the appointment. For more information, please visit here.

Well Child Examination Vaccine Fees for New Patients

This is a comprehensive listing of visits by age, the total fees billed to insurance and procedure codes billed. Useful for when contacting your insurance to verify what procedures are covered or not. This form is required at time of check in so it is best to call your insurance before the appointment. For more information, please visit here.

Disclosure of Medical Information Form

This form designates who you wish for us to communicate your child's health information. This is more commonly used for extended family such as grandmothers and/or nannies.