Forms and Policies

ACD Pediatric Group Logo
3416 W. 84 Street, Suite 100
Hialeah Gardens, FL  33018
Phone: 305 826-9449
Fax: 305 828-1255

patient forms

Downloadable Forms

For your convenience, ACD Pediatric Group has posted a number of commonly used forms that you may be asked to complete during your visit to our office. These forms are available in PDF format, and are available for you to download, print and complete prior to your visit. By completing forms ahead of time, you can minimize the amount of time you spend at our office.

Patient Information Form

Pediatric History Form

Parental Consent Form

Record Release Authorization Form

Notice of Privacy Practices - English

Aviso Acerca de las Practicas de Privacidad - Español

Acknowledgment of Receipt of Notice of Privacy Practices

Self Pay Acknowledgement Form

ACD Pediatric Policies Form