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Patient Forms

For your convenience you may print and complete the following forms
prior to arriving for your appointment.

Physician Office Consent for Treatment and Financial Agreement

Permission for Medical Treatment of a Minor

Forms needed for Vanderbilt ADHD Evaluation:

Parent Letter
Consent to Release Private Data
Vanderbilt ADHD Diagnostic Parent Rating Scale
Behavioral/Developmental Patient History
Teacher Letter
Vanderbilt ADHD Diagnostic Teacher Rating Scale

Wheaton Franciscan Healthcare is committed to living out the healing ministry of the Judeo-Christian tradition by providing exceptional and compassionate healthcare services that promote the dignity and well being of the people we serve.

Learn more about our Mission, Vision & Values >

Quick Links

Covenant Clinic Locations

The Wheaton Franciscan System is committed to protecting the privacy and confidentiality of patients protected health information and has had practices
in place for many years to respect patients right to privacy. In response to the Health Insurance Portability and AccountabilityAct of 1996 (HIPAA),
we are pleased to provide our patients with a Notice of Privacy Practices as they enter our facilities for health care services.

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