South East Bay Pediatric Medical Group :: Fremont, CA : General Pediatrics for Newborns, Infants, Children, Teenagers

2191 Mowry Ave, Suite 600C
Fremont, CA 94538
(510) 792-4373
Hours & Location

Physicians

Services

Office Policies

Appointment Request

Forms

Billing & Insurance

Patient Education

Links

Site Map

Other Forms

ADHD Parent Packet - introduction to the process and the questionnaires with a Health History Form
ADHD Parent Questionnaires - to be answered by each parent individually
ADHD Connors and Vanderbilt Parent Questionnaires - to be answered by each parent individually

ADHD Teacher Packet – given to the main teacher, principal, counselor, or other administrator who can provide the requested information
ADHD Teacher Questionnaires - given to 1-3 teachers who have direct observation of and/or supervision over your child
ADHD Connors and Vanderbilt Teacher Questionnaires - given to 1-3 teachers who have direct observation of and/or supervision over your child

ADHD Teen Patient Checklist - questionnaire teenagers fill out for themselves
ADHD Teen Patient Parental Observation Checklist - questionnaire for parents about their teenagers

Health History Questionnaire - general health questionnaire for all new patients
Patient Contact Information Form - contact information for patients and their family
Health Plan Eligibility Certification Form
Consent for Treatment Form - consent to treat a minor and acknowledgement of policies at South East Bay Pediatrics
Vaccine Designee Consent Form - allows another adult other than the child's parents(s) to sign for vaccinations
Consent for Elective or Travel Vaccines

Authorization to Release Medical Records TO South East Bay Pediatrics - allows us to obtain medical records, including growth curves and immunizations, from your previous pediatrician
Authorization to Transfer / Copy/ Inspect Medical Records FROM South East Bay Pediatrics - request to transfer records to another physician outside of our practice, copy medical records for your files, or examine your child's chart