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WASHINGTON UNIVERSITY CLINICAL ASSOCIATES

Northwest Pediatrics

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Forms

New Patient Forms

Please bring these forms to your first appointment:

  • New Patient Form (PDF)
  • Consent to Treat Form (PDF)
  • Request a Copy of Your Medical Records (for yourself) (PDF)
  • Request Medical Records Release (to a third party) (PDF)
  • Patient Communication Form (PDF)
  • Electronic Communication Form (PDF)

MyChart Forms

  • MyChart Proxy Form Ages 0-11 (PDF)
  • MyChart Form for Patients Ages 12-17 (PDF)
  • MyChart Proxy Form Ages 12-17 (PDF)

Other Forms

  • Prenatal Interview (PDF)
  • New Family Interview (PDF)
  • M-CHAT Survey (Autism) (PDF)
  • Missouri Sports Participation (PDF)
  • Illinois Preparticipation Form (PDF)
  • Patient Health Questionnaire (PHQ-9) – Patient Depression (PDF)
  • GAD-7 Anxiety Questionnaire (PDF)

Vanderbilt Assessment Scales (ADHD)

  • Vanderbilt Assessment Scale—PARENT (PDF)
  • Vanderbilt Assessment Follow-up—PARENT (PDF)
  • Parent Assessment Scale (Vanderbilt Addendum) (DOC)
  • Vanderbilt Assessment Scale—TEACHER (PDF)
  • Vanderbilt Assessment Follow-up—TEACHER (PDF)

Northwest Pediatrics

Washington University Clinical Associates (WUCA)

Wentzville: 636-332-6663

St. Charles: 636-441-7280

Florissant: 314-837-0405

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