Phone (859) 441-7600 | 1805 Alexandria Pike | Highland Heights, KY 41076

 

 

 

 

 

 

 

 

 

Forms

Confidential Patient Information form- all new patients or patients with changes in insurance or address need to fill out this form. 

Note: files on this page will open in a new window

• Privacy Information - all new patients need to read this information and sign the attached form. 
• Confidential Patient Information Form
• Asthma Form- should be filled out at least yearly for all asthma patients 
• Change of Address Form
• Sports and School Forms
  • Kentucky sports form
  • Ohio sports form
  • Kentucky school forms
• ADHD Forms
  The Vanderbilt Parent and Teacher Assessment Forms must be filled out and mailed to our office prior to an appointment to discuss if you child may have ADHD.   The Vanderbilt Parent and Teacher Followup forms must be filled out and mailed to our office for any patient diagnosed with ADHD prior to a well check or an ADHD check.  The followup forms should be filled out at least yearly for any patient who has been diagnosed with ADHD
  • Vanderbilt Parent Assessment Form
    
  • Vanderbilt Teacher Assessment Form 
  • Vanderbilt Teacher Followup Form
  • Vanderbilt Parent Followup Form