Your Visit > Forms

Forms & Policies

Our PAK staff will complete your  physical form free of charge during your yearly well visit. All forms must be given to the CCS when in the room for your appointment; only forms presented in the room  will be processed at the time of your appointment.

Additional forms or forms brought to our offices during normal office hours will be completed within 2-5 days for a $15 service fee.  For us to complete a form, your child’s well visit must have been within the time frame recommended for his or her age: within the last 12 months of school-aged children, or shorter intervals for younger children.

Here are some common forms used by PAK patients and families. Just click on the links for PDF copies you can download, print, begin to fill out, and bring to our offices for your next visit:


Back To School

School Vaccination Information For Parents
School Vaccination Requirements

Welcome Packet

Welcome Packet Part 1 (Read Only)
Welcome Packet Part 2 (Print & Return)


ADHD Vanderbilts Parent and Teacher
ADHD Adult Forms

Health Forms

State of Pennsylvania Child Medical Examination
PIAA Sports Physical Form 2019 (Section 5 Health History must be completed by parent for the physician to review)
Non Commercial Drivers License Application


Download and complete prior to appointment
Peak Flow Meter Instructions
Asthma Assessment 5 yrs and older
Asthma Control Test
Asthma Follow Up 12 yrs and older
GERD Education

New Patient

Financial Policy
Privacy Policy
Medical Records Request to PAK


Informational packet to explain young adults responsibility with his/her account.
Medical Records Release from PAK
Authorizes selected individuals to accompany, provide consent for treatment, and or receive protected health information about the pediatric patient.
Patient Portal Enrollment Form

Is Your Child Sick?TM

451 3rd Avenue, SUITE 1 | Kingston, PA 18704 | Phone: 570-288-6543
1081 Oak Street | Suite 1 | Pittston, PA 18640 | Phone: 570-602-PAKP
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