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  New Patient Forms  

FOUR (4) required forms are in .PDF files that you can download, read, type into, and print by using the FREE Adobe Acrobat Reader that must first be installed on your computer. 

Our New Patient Forms will download after you click on each of the New Patient Forms links below. Each is in a "fillable" .PDF file that cannot be submitted electronically from this Web site.

Instead, you must print out each of the forms and bring them with you on your first visit to our office, but please continue reading this page.

When viewing a downloaded form, if data entry fields where you can type necessary information are not highlighted, there may be a check box in the upper right hand corner of the form's window with the words Highlight fields that you can click to cause the data entry fields to become highlighted.

After you click on and try to type into the first fillable data entry field, there may be a delay of 30 seconds until Adobe Reader displays a message box - close the message box and you can proceed to enter data.

Whenever a Yes or No choice is presented,

CLICK on either Yes or No, your choice will be marked, and it will print as circled after you print that form!


*If you don't have the current FREE Adobe Acrobat Reader installed,

CLICK the Get Adobe Reader® stamp below:




Below are links to the New Patient Forms - please CLICK on each of the links for the FOUR (4) REQUIRED forms you must complete:


1. Child's Initial History Questionnaire - (one for each child)


2. CCW - Financial & Office Policy


3. CCW - Patient Acknowledgement of Policy for Protection Against Identity Theft, HIPAA Disclosure, and Other Party Authorization to Treat 


4.  CCW  - Consent to Treat - (one for each child) 



A. Transfer & Copy of Records TO CCW-REQUEST FOR RELEASE OF MEDICAL INFORMATION - TO CCW from another medical office


B. Transfer & Copy of Records FROM CCW-REQUEST FOR RELEASE OF MEDICAL INFORMATION - FROM CCW to another medical office- with Fees



Reminder to New Patients: To shorten the length of your office visit please complete:

 #1 Child's Initial History Questionnaire

 #2 CCW - Financial & Office Policy

 #3 CCW - Patient Acknowledgement of Policy for Protection Against Identity Theft, HIPAA Disclosure, and Other Party Authorization to Treat 

  #4 CCW - Consent to Treat - (one for each child)

  ... and bring all FOUR (4) required forms with you.


The staff at Children's Clinic thanks you!


The Children's Clinic of Wyomissing, Inc. · 2240 Ridgewood Road - Suite 100

  Wyomissing, PA 19610  (610) 376-8691

Dedicated pediatricians and staff serving greater Reading, PA & Berks County

Copyright © 2004-2018  The Children's Clinic of Wyomissing, Inc. All rights reserved.

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