Red Bank (732) 741-0456 Wall (732) 681-0300
- Compehensive Health Care for Kids of All Ages
Patient Info
New Patients
Information for New and Prospective Patients is outlined below.
Brochures
- Practice Brochure
- HIPAA Privacy Notice
- Your Health Plan Coverage and Our Financial Policies
- BCD Financial Policies Page
Prior to your first visit, we would like you to complete new patient forms so that we may obtain all previous records you or your child may have.
Forms
The new patient packet includes the following information. Please print out and complete these forms prior to arrival
- Family Information Sheet
- Insurance Information Form
- Financial Policy Acknowledgement Form and Waiver **
- HIPAA Policy Acknowledgement Form
- Alternate Caregiver Permission Form
- New Patient Questionnaire
** Please do not sign this form until you have read all the sections of the Financial Policy above.
Current Patients
School Forms
- Universal Child Health Care Record
Provided for Grades K through 5 . - Athletic Pre-Participation Physical Examination
Please print out this form and complete the History (Page 1, complete page 2 for children with disabilities) before you bring your child for a physical exam. (6th grade and older) Pages 3 and 4 will be provided.
Please print out this form and complete the history portion before you bring your child for a physical exam. (6th grade and older)
Treatment Plans
ADHD Screening Tools
Additional Screening Tools
- M-CHAT – please bring to 18 month physical