Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
"Dr. Southerland is a fantastic pediatrician, she answers all questions and explains everything. I couldn’t be happier with her services!"
Patient Forms
Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Paradise Pediatrics New Patient Registration Forms
Paradise Pediatrics Family History Form
Paradise Pediatrics Medical History Form
Paradise Pediatrics Lifetime Signature Form
Paradise Pediatrics E-Prescribe Form
Paradise Pediatrics ADHD Forms
ADHD-Parent/Patient Follow-Up Form
ADHD-Teacher Follow-Up Form
ADHD-Vanderbilt Parent Initial Form (First Visit Only)
ADHD-Vanderbilt Teacher-Initial Form (First Visit Only)
Paradise Pediatrics Allergy Information
Allergy Testing Information and Patient Instructions
Allergy Immunotherapy Information
Office Policies
Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)