University of New England

Patient Forms

Welcome to UHC for Kids!

Please fill out the appropriate forms before you come in for an appointment. You can download and complete the forms at home to save time when you arrive. The forms are electronic documents in .pdf format.

New Patients

In addition to completing these forms, please contact your insurance company and add our pediatrician as your child’s primary care provider.

• Registration Form (2 pages)
• Pediatric History Form (2 pages)
• Well-Child Form (See below)

Established Patients

• Well-Child Form (See below)
• Registration Form – Complete for the 1st visit of each new year.
• Records Release Form – Complete when you need records sent to another provider.

Well-Child Visits

New and established patients should complete the well-child form for the patient’s age.

• Well-Child: 0 – 2 weeks
• Well-Child: One month
• Well-Child: Two months
• Well-Child: Four months
• Well-Child: Six months
• Well-Child: Nine months
• Well-Child: 12 months
• Well-Child: 15 months
• Well-Child: 18 months
• Well-Child: Two years
• Well-Child: Three years
• Well-Child: Four years
• Well-Child: Five years
• Well-Child: Six – eight years
• Well-Child: 9 – 11 years
• Well-Child: 12 – 14 years + Adolescent Health Survey
• Well-Child: 15 – 18 years + Adolescent Health Survey

Counseling and Mental Health

It is the patient’s responsibility to obtain an insurance referral prior to the visit (phone number on the back of insurance card).