Download Patient Forms

Quickly and conveniently obtain forms from our office. By filling out these forms ahead of time, you will save time during your visit.

• Notice of Privacy Practices

• Protected Health Info Consent Form

• Yearly 3-11 yrs History form

• Yearly 1-2 yrs History Form

• Yearly 12 yrs & older History form

• New Patient Birth to 3 yrs Questionnaire

• New Patient 3 yrs and older Questionnaire

• Yearly 18 & 24 mths M-CHAT-R form

• LPA Vaccine Policy

• Parent Vanderbilt Assessment

• Teacher Vanderbilt Assessment

Note: These files are in PDF format. If you do not have Adobe Reader on your computer, you can download it for free at www.adobe.com

Medical Records

If you need to request medical records for transferring to other physicians or transferring into our office, please select the appropriate form below.  You may mail, deliver or email medrecords@lancped.com the completed form to our office. Signatures must be verified prior to transferring.

• Authorization to transfer medical records from LPA

• Record Transfer from other Dr’s office to LPA

• Medical Records Fees

No Show Policy

<< 24 –hour notice minimum required for cancellation via phone or patient portal >>

Patients who fail to keep scheduled appointments, the following occurs:

• Patient is contacted by phone (one attempt) and by letter or email.

• If missed appointment occurs twice, patient is dismissed from the practice unless there are mitigating circumstances.

• Patients will be charged a broken appointment fee.