Fellsway Pediatrics Forms

We may ask you to fill out a certain form before an appointment. Clicking on a link below will bring up a PDF file that you can print and fill out before you come to the office.

If you prefer, we can mail you the form. Just let us know by calling 781-665-4364.

PDF Forms

• Patient Registration Form
• Release of Information  (Fill out when giving permission from a specialist or other office to send us patients records)
• Consent to Treatment  (Notice of HIPPA Privacy and Financial Release of Information)
• Authorization for Medical Treatment of a Minor  (Fill out when someone other than a guardian is bringing a minor in for the appointment)
• Authorization for PHI Release (Transfer)  (Parents fill this out when transferring from this office to another primary care)
• Authorization for Disclosure of Health Information (18 and Up)  (18 year old giving consent to have their medical information released to someone else)

Video Recording Policy 

Video recording is not permitted at any time while in our office. Video recording could result in an inadvertent violation of privacy. If you would like to take a still picture while in our office, you must ask and obtain permission from any staff member or other patient or family member in the room.

Information Charts

• Understanding Fever and Dosing Information for Infants and Children (Tylenol, Motrin, Benadryl)