Instructions
We are committed to providing high-quality primary care that includes your child's individual healthcare needs. Our services are available only to registered patients who have completed registration and had their records transferred to Mack Pediatrics.
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Find the forms appropriate for your child, either to register as a new patient or to prepare for an upcoming appointment.
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Print, complete and bring-in those forms as instructed.
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Registration
We are not accepting new patients at this time, with the exception of newborns. We may resume acceptance of new patients in mid-2024. Thank you for you interest. --Dr. Mack, update 1/30/24.
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HIPAA for privacy of protected health information (for your review only)
New Patient Registration
Sibling of New Patient Registration
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Request for Special Records (specialist, x-ray, etc)
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Separated/Divorced Custody Agreement Form--for families with separated or divorced parents, please submit this form signed by both parents/guardians with initial registration or when requested.
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Well Visit
Wellness visits (including check-ups, sports physicals) involve lifestyle and health screening questions. Many of these can be done prior to visit by using the portal* to check-in. There are 2 sets of age-specific questions to complete on the portal* or office tablet for each wellness check. The forms below are also required for the specified wellness checks, and can be printed and completed at home prior to the visit or will be provided in office at check-in.
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Edinburgh (for 1, 2, 4 and 6-month wellness visits)
9-month Development Screen--ideal to print, complete & bring to the 9-month visit.
18-month Development Screen--ideal to print, complete & bring to the 18-month visit.
MCHAT-R (for 18- and 24-month wellness visits)
Development Screen (3 to 5 year-old wellness visits)
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*Our patient portal (called YourHealthFile) is accessible by your smart-phone (or similar device), tablet or computer. If your child is a registered patient and has been seen at Mack Pediatrics for clinic visit, then you should have received a portal invitation to the email that you provided in the registration packet. If you have not received a portal invitation or the invitation has expired, please call for a portal invitation email (from "HF Alerts").
Consultation
ADHD
Consultation appointments are available only for established patients. The appointment is 60-90 minutes long and requires careful planning. It is usually scheduled around 2pm. Parent should expect the receptionist to be unable to schedule a consultation until Dr. Mack authorizes the appointment.
Consultations are for a variety of behavioral or emotional concerns, though most commonly are for the diagnosis of ADHD. Consultations are not wellness checks or appointments for non-behavioral concerns, and cannot be combined with other appointment types. The child is not present at the consultation. The child must have been examined by Dr. Mack within 6 months of the consultation and be current on annual wellness checks.
For ADHD initial consultation, please complete from the forms provided below the ADHD Initial Consultation, ADHD Initial Vanderbilt and bring recent report cards (and any other evaluations, reports that are relevant). Dr. Mack requires 7 days to review the forms, reports and evaluations prior to the consultation appointment. If the requested paperwork is not completed and given to Dr. Mack 7 days prior to the appointment, the appointment may be rescheduled.
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ADHD Medication Follow-up Visit
ADHD Medication Refill Request
ADHD RS-IV Teen Self-Assessment
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SCARED preschool anxiety screen