Forms

Bring to your first visit

• New Patient Information Form - Type in the blanks on this form before you print it. (User-interactive PDF)
• Privacy Policy/HIPAA Form (PDF)
• Patient History Form (PDF)

Due to the nature of our practice, our physicians routinely perform complete physical examinations, including genital exams.

A parent or legal guardian must be present at all office visits.

Relatives, caregivers, and friends may accompany your child to an office visit with a notarized Medical Power of Attorney. Handwritten notes will not be accepted.

Medical Records Release

To protect your family's privacy, we require a signed Medical Records Release form each time you request
a copy of your child's medical records.

• Medical Records Release Form

Medical Records Release forms may be faxed to (602) 264-0461, mailed to Pediatric Urology Associates, 1920 E. Cambridge Ave. #302, Phoenix, AZ 85006, or hand carried to any of our four locations.