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Forms & Consent Policies

Metropolitan Pediatrics has consent policies requiring forms be completed before sharing our child’s medical information with requesting organizations such as schools and daycares. You can download the consent forms listed below.

Form Completion Request

  • Use this form to request records for sporting activities, school, daycare, asthma action plan, allergy action plan, immunization record or medication administration requests sent to any facility.
  • We are required by law any time we send protected health information (PHI) to an outside entity that we must have a parent, legal guardian or legal adult child (age 18 or older) consent form signed for each request (one request per form).
  • We do not need forms your daycare or school (elementary or high school) provide to you. We do need forms for colleges, Scouts of America, HeadStart and medication administration forms to complete the Form Completion Request.
  • When this form is complete, you can drop it off, mail it or FAX it to the clinic that routinely sees your child.
  • As are reminder, you child needs to be up-to-date on physical exams to complete any forms. It may take up to 72 hours for completion of your request.

Medical Record Release Form

Use this form if you are transferring your child(ren) out of any of our clinics, need specific records shared with a specialist your child(ren) may be seeing, and/or if you are applying for disability benefits or other health care option benefits and law firms. If the child is 18 years old or older, they can sign the form themselves or they must have the 18 Year Old Waiver [18 Year Old Waiver or Consent] that allows parents to sign for their adult children on file with Metropolitan Pediatrics. This release cannot be used for a single form request.

18 Year Old Waiver or Consent

According to Minnesota law and the HIPPA privacy rule, when patients turn 18 years old they are considered adults and parents and guardians can no longer access the patients’ medical information without your child’s written consent. Please have your child fill out this consent form if they would like to provide consent for you (or anyone else) to view their medical record.

Medical Consent for Minors

Use this consent form to give your permission for another caregiver to temporarily authorize treatment for your child (under 18 years of age) in your absence. This form could be used if you are going out of town, for example, and you are designating care to someone in your absence.

In our practice we use various assessment tools. Below you will find those assessment tools.

Acute Concussion Evaluation (ACE) Physician Office

ADD-ADHD Vanderbilt Assessment Scale-Parent

ADD-ADHD Vanderbilt Assessment Scale-Teacher

ADD-ADHD Vanderbilt Assessment Follow-Up-Parent

ADD-ADHD Vanderbilt Assessment Follow-Up-Teacher

Childhood Asthma Control Test for Children 4 to 11 Years

Childhood Asthma Control Test for Children 12 Years and Older

Edinburgh Postnatal Depression Scale (EPDS)

Generalized Anxiety Disorder Questionnaire (GAD-7)

Modified Checklist for Autism in Toddlers (M-CHAT-R/F)

Patient Health Questionnaire (PHQ-9)

Pediatric Symptom Checklist-Parent

Pediatric Symptom Checklist-Youth

Screen for Child Anxiety Related Disorders-Child

Screen for Child Anxiety Related Disorders-Parent

Other forms are used for administrative purposes such as onboarding a new patient. Those forms are listed below.

Consent for Post-Partum Depression Screening

General Consent

New Patient Health Background

Patient Demographics and Insurance