Forms

Medication Authorization Request Form is to be filled out completely by the patient or guardian in order for Wildwood Pediatrics to begin the process. We provide medication authorization forms for acetaminophen (Tylenol), ibuprofen (Motrin, Advil) and diphenhydramine (Benadryl) free of charge.  For all other medications we charge a flat free of $15 per patient.   In general, the doctor or practice that prescribed the medication should be the one supplying the authorization form for it. To begin the process, please print the Medication Authorization Request Form below, fill out and bring in to one of our offices.

• Medication Authorization Form

Authorization for the Release of Patient-Identifiable Health Information

• Record Release Form

Patient Privacy and following the law is of upmost importance for us. There are laws affecting the handling of patients’ medical information and they formalize much of what we have always done here at Wildwood to protect your right to privacy. However, they do affect some common situations, restricting our ability to take shortcuts, even with your permission, even as a courtesy to longstanding friends and patients. 

• Privacy Policy

Your feedback is important to us! 

• Patient Satisfaction Survey