Immunization, Health, School Activity and Other Forms
New Patient Forms:
You may also want to print and complete the Standard Disclosure
Form, the School/ Daycare Release Form, the Records Release Form
as well as sign up for chart access through the Patient Portal.
Forms For Patients Over 18:
Authorization To Use/Disclose Protected Health Information:
Questions about which form is right for you? Contact our Medical
Records department at (513) 231-3345, option 6.
The History page MUST be completed by the parent/
caregiver prior to dropping off the form.
School/Daycare Health Forms:
Please enter only your child’s
name and date of birth
Vanderbilt Assessment Forms:
If your child has an upcoming
ADHD evaluation appointment you may print the necessary forms here.
You may also access these forms through the patient portal and
invite your child’s teacher to complete their assessment
online as well.
Call for more information if you reside in Eastgate, Amelia,
Milford, Bethel or Anderson.