Our financial policies

Please take a moment to review our financial policies and current fee schedule:

Ridgefield Pediatrics Financial Policy
Ridgefield Pediatrics Fee Schedule

Our forms

The following forms are in PDF format and can be downloaded, completed at your convenience, and brought to the office at the time of your appointment.

General patient forms

Forms may be printed and completed prior to your appointment with us.

Health History Form
HIPAA Acknowledgement and Consent Form (please read our HIPAA Privacy Policies before signing)
HIPAA Consent Form (18 years or older)
Authorization for Release of Patient Information/Records
Minor Consent

Registration form

Registration Form 2017

Travel form

International Travel Questionnaire
Medical and Allergy Information

School forms

School forms and Pre-school forms are done free of charge if they are required as a mandatory form for school entrance or grade acceptance. We suggest parents keep the school form on file for the years it is mandated and try to use this form when applying to camp. School forms can be obtained from your child’s school office.

Camp forms

We have a $5.00 charge for camp forms. Camps usually have their own forms, and each camp’s form is different. It takes time for our staff to input the information that is necessary into this form and then each form must be reviewed by a provider and signed off on, assuring that all medical information is updated and accurate. We need approximately two weeks to complete the camp forms. If you need the form within 48 hours, there will be a $20.00 rush fee. We have thousands of camp forms to complete each summer and having you get them to us early in the summer is appreciated.

Screening forms

Impact Testing Questionnaire

Vaccine charts

Reasons to Vaccinate: Vaccine-Preventable Diseases and the Vaccines that Prevent Them
Regular and Alternate Immunization Schedules and Standing Orders for Ridgefield Pediatrics