Forms

If you are new to Magnolia Pediatrics,  please fill out the "new patient" and "medical record release" forms before coming to your first appointment.  This will expedite the check-in process when you arrive to meet the doctor. 

The Medical Record Release form allows your previous doctor to send us your medical records, which we would like to review before your visit. 

Thank you for your cooperation in making your visit to Magnolia Pediatrics a pleasant and efficient one. 

New Patient Forms

Magnolia Pediatric Registration Form (PDF)

UBCP MPM Privacy Form (PDF)

My Chart Proxy 0-11 yrs (PDF)

My Chart Adolescent Proxy 12-17 yrs (PDF)

Records Requests

Releasing Information to Parents Tipsheet (PDF)

Medical Records Release (PDF)

We are happy to complete school, sports and camp forms for your child.  Please remember to bring them along to your visit.  Forms submitted at other times will incur a $20 fee, reflective of the time we take to carefully review your child's health history.  Please allow us 3-5 days for form completion. 
Office Hours: Monday-Friday 9AM TO 5PM
Please call during office hours to set up an appointment to speak with our staff.
 
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