MILFORD
203-882-2066
321 Boston Post Road
Milford, CT 06460

STRATFORD
203-380-4083
225 Hawley Lane
Stratford, CT 06614
MILFORD
203-882-2066
321 Boston Post Road | Milford, CT 06460
STRATFORD
203-380-4083
225 Hawley Lane | Stratford, CT 06614

Home » Forms & Downloads

New Patient Forms

The Milford Pediatric Group offers patient forms you can fill out online from the convenience of your home or office. Click on the necessary form(s) below and upon completion, click "Submit".

General Practice Forms

Patient Information Form:
Downloadable PDF
Online Form
Patient Over 18 Years Old Information Form:
Downloadable PDF
Online Form
Patient Directed Release Form:
Downloadable PDF
Online Form
No Show Policy:
Please see our office policy for no showing appointments.
  • First Missed Appointment: A $25 charge and a letter outlining our policy
  • Second Missed Appointment: A $50 charge
  • Third missed Appointment: You will be discharged from our practice
If there is a missed appointment fee on your account it must be paid in full prior to scheduling any new appointments.

School Physical Forms

Early Childhood Health Assessment Record (ED 191)
Downloadable PDF
Health Assessment Record (HAR-3)
Downloadable PDF
Authorization for Administration of Medication Form
Downloadable PDF

HIPAA Forms

HIPAA Authorization Form for Over 18 Years Old:
Downloadable PDF
Online Form
HIPAA Authorization Form for Parents/Guardians:
Downloadable PDF
Online Form

Sports Forms

Pop Warner Physical Fitness & Medical History Form
Downloadable PDF

Ask Us a Question

Please enter your name.
Please enter a valid phone number.
Please enter a message.
Satellite Office – Stratford
225 Hawley Lane
Stratford, CT 06614
203-380-4083

Monday - Friday8:00am - 6:00pm
Saturday - SundayCLOSED
Main Office – Milford
321 Boston Post Road
Milford, CT 06460
203-882-2066

Monday - Friday8:00am - 6:00pm
Saturday - Sunday9:00am - 12:00pm
Acute sick appointments available as necessary after 6:00PM

Copyright © 2019 Milford Pediatric Group | Web Design by SMB Networks, LLC | Privacy Policy | 1557 Nondiscrimination Notice