Patient Forms

• TeleMed service allows a parent/guardian to seek remote medical advice and guidance from a provider at the Children's Clinic of Wyomissing for the care of a child who does not have an emergency condition...CLICK HERE to learn more, and email your completed TeleMed Consent Form to care@ccwyo.hush.com
• Need Help with forms? See Below.

SEVEN (7) 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 SEVEN (7) REQUIRED forms you must complete and bring with you on your first office visit. By completing these forms before your visit, you will shorten the length of your office visit:

1. Child's Initial History Questionnaire - (one for each child)
2. Patient Registration Form
3. Notice of Privacy Practices
4. All Policies Acknowledgement Form
5. Transfer of Records to Children's Clinic from another medical office
6. Vaccine Schedule and Policy
7. Patient Portal Handouts

The staff at Children's Clinic thanks you!

A. For Transfer of Medical Records from CCW to another health care provider, click on this link.

B. For PIAA Form, click on this link.

C. Risk Assessment Questions

• Risk Assessment 0-5
• Risk Assessment 6-18
• Risk Assessment 18+

D. Young Adult Confidentiality Release Form

E. Vaccine Policy

F. Flu Mist Questionnaire

G. Prevaccination Checklist for COVID-19 Vaccines

H. COVID-19 Vaccine Patient Information Sheet

I. 2nd DOSE COVID-19 Vaccine Forms (MUST Have Had 1st Dose)

If you have forms, need a copy of immunizations, or have paperwork that needs our attention, please let us know or e-mail us at care@ccwyo.com . We will assist you in obtaining the information and save you a trip to the office!