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Forms & Policies

The following forms and policies are provided for your information and convenience. You may download and print any of our forms listed below before coming to our office. This will get you out of the waiting room and in to see the doctor a lot quicker! You may either bring them with you to the first visit, or if you wish, fax them to us at 303-426-9581 before your appointment.

Expectant Parents and Parents Seeking a New Pediatrician

Whether you are expecting your first child, or shopping for a new pediatrician for your children, finding the right pediatrician for your family is a very important undertaking. We welcome the opportunity to meet with you anytime to show you around our offices, and answer any questions you may have. Please call 303-430-0823 Monday through Friday, 8:00am to 5:00pm to schedule a consultation appointment.

New Patient Registration Packet

Contact Information and Acknowledgement of Receipt of Policies
Please read the Privacy Rights and Financial Policies available in the last section of this web page before signing this document.

Patient Medical History

Authorization for Child's Treatment
(Permission for an adult other than parent or guardian to seek treatment for a child. This is only required if a non-guardian adult will be bringing your child to an appointment.)

Patient Registration Form

Existing Patients

Change of Patient Contact Information
Please call changes into your Mountainland Pediatrics office or the Billing Office at 303-853-3440.

M-CHAT Questionnaire
The Modified Checklist for Autism in Toddlers (M-CHAT) assesses risk for Autism in children between the ages of 15 and 30 months and is usually done during a well-child visit. Please read the additional explanation document below for more information.

M-CHAT Explanation
The Modified Checklist for Autism in Toddlers (M-CHAT) assesses risk for Autism in children between the ages of 15 and 30 months and is usually done during a well-child visit. This document is the explanation. The questionnaire is above.

Mountainland Pediatrics Record Release
To have your child's records sent to another person

Change of Responsible Person and/or Insurance
Please complete a new Patient Registration Form

Policies

Mountainland Pediatrics Office and Financial Policies 2010

Mountainland Pediatrics Privacy Rights