Patient Forms

Please arrive 15 minutes before your scheduled appointment to complete any outstanding paperwork, provide your Insurance Card for scanning and your Credit Card information. If your child is older than 4 months, you may call the office to schedule a new patient well check. 

Appointment availability may vary based on demand. Currently we are scheduling new patients over 4 months old in January 2025. If you are interested in establishing care with RTC Pediatrics, please complete the age-appropriate intake forms below. You will be contacted within 5 business days to schedule the next available new patient well visit appointment. 

For new patients up to 4 months old, we have appointments reserved each week for new baby well visits. If you have a baby 0-4 months old, call our office to get scheduled right away.

• Patient Registration - One form for entire family
• Newborn Questionnaire - One per patient under 12 months old
• Pediatric Questionnaire - One per patient over 12 months old

• HIPAA Notice of Privacy Practices: Full Notice
• HIPAA Patient Consent Form
• Consent Form for Patients 18+
• RTC Pediatrics Authorization Form for Appointment and Treatment
• RTCP Consent Form for Medical Ear-Piercing
• Telemedicine Consent Form
• Financial Policy
• Release Medical Records from RTCP
• Patient Conduct Policy

Please arrive 15 minutes before your scheduled appointment to complete any outstanding paperwork, provide your insurance card for scanning and your Credit Card information.

Ages 2-6 months

• Patient Registration
• Postnatal Depression Scale

Ages 12 months and older

• Patient Registration

Ages 18 months and older

• M-CHAT

Girls ages 13-17 years, Boys ages 14-17 years

• Patient Registration
• Adolescent Questionnaire
• Parent of Adolescent Questionnaire

Age 18 years

• Patient Registration
• Adolescent Questionnaire
• Parent of Adolescent Questionnaire
• Consent Form for Patients 18+

ADHD Vanderbilt Assessment

• Vanderbilt (Parent)
• Vanderbilt (Teacher)
• Follow-Up Vanderbilt (Parent)
• Follow-Up Vanderbilt (Teacher)

Med Trial

• Med Trial Directions for Parents and Teachers
• Med Trial-Parent
• Med Trial-Teacher

Screen for Child Anxiety Related Disorders

• SCARED (Child)
• SCARED (Parent)

Mood & Feelings Questionnaire

• MFQ (Child)
• MFQ (Parent)

We are going Green! Starting June 15, 2024, after a completed Well Check, Virginia School Forms will be shared to the patient portal. If a printed copy is required, there is a fee of $20 per printed form.

Please bring any other forms that require a provider’s signature with you to your child’s yearly physical exam, so we can complete them at no additional cost to you. Please ensure that you complete all components of that form prior to your child’s arrival at our office.

If the necessary forms are not presented at the time of the yearly physical exam, but rather brought in or mailed to our office for completion after that visit, you will be charged a $20 administrative fee for each form.

If you need the form(s) in less than 72 hours, the charge is $20 for each form PLUS an extra $25 rush fee for the form(s).

For example, if a family is requesting 3 forms for 3 children with a rush request, the total charge is $60+$25 = $80 Total for forms.  Fees will be due prior to pickup of the completed forms.

If you are requesting that our office mail your child’s form back, you will need to send payment along with that form. Please be aware that these fees are not covered by your medical insurance policy.

We are going Green! Starting June 15, 2024, after a completed Well Check, Virginia School Forms will be shared to the patient portal. If a printed copy is required, there is a fee of $20 per printed form.

• VA School Entrance Health Form
• Virginia Sports Form Questionnaire - This Form must be filled out on May 1st or later.
• TB Screening - Please fill out and hit the Submit button.