Patient Forms

Patient Forms are in PDF format.  Adobe Reader is required.  Click here to download Adobe Reader for free here.

These forms are available in Spanish upon request at (702) 641-2150.

18-24 Month Developmental Screening (M-CHAT) - English

18-24 Month Developmental Screening (M-CHAT) - Spanish

Childhood Autism Spectrum Test (CAST) - English

Childhood Autism Spectrum Test (CAST) - Spanish

ADD ADHD - Family

ADD ADHD - Teacher

Authorization for Disclosure of PHI

Personal Information Sheet

Record Request

Registration Packet – Private Insurance –  Newborn-4 Years

Registration Packet – Private Insurance – 5 Years and Older

Registration Packet - Cash Newborn - 4 Years

Registration Packet - Cash 5 Years & Older

Registration Packet - Medicaid - Newborn-4 Years

Registration Packet - Medicaid - 5 Years and Older

Temporary Medical Guardianship

Treatment Authorization

HIPAA Notice of Privacy Practices



Home | Meet Us | Locations | Patient Forms | Insurance | Office Policies
Expecting | New Patients | Child Illness | Affiliations | Medical Library | Helpful Links

2150 S. Eastern Ave
Las Vegas, NV 89104
Phone (702) 641-2150
Fax 702-641-8667

7180 Cascade Valley Court #180
Las Vegas, NV 89128
Phone (702) 641-2150
Fax 702-228-1043
1840 E. Sahara #212
Las Vegas, NV 89104
Phone (702) 892-8007
Fax (702) 892-8193

This website has been designed by Desert Pediatrics to provide information of a general nature. It is not intended to be a substitute for the medical advice provided by one's practitioner. Visiting the website DOES NOT establish a patient-physician relationship with any physician or practitioner associated with Desert Pediatrics. If you need information of a specific nature, please contact our office.

©2010-2020 AMB Web Design LLC

Patient Forms Back to home page Desert Pediatrics Locations Insurance Office Policies Meet us