Patient Forms

New Patient Forms

You can download the following forms or pre-register on our secure Patient Portal.

Child Health Form
Initial History Form.pdf
Adobe Acrobat document [127.3 KB]
Patient Registration Form
New Patient Form.pdf
Adobe Acrobat document [65.8 KB]
Financial Responsibility Form
Financial Responsbility Form.pdf
Adobe Acrobat document [154.7 KB]
Cancellation Form
24 hours Advance Notice Document.pdf
Adobe Acrobat document [116.3 KB]
HIPPA form
HIPPA form.pdf
Adobe Acrobat document [949.2 KB]
Credit Card Policy
Credit Card Policy.pdf
Adobe Acrobat document [278.4 KB]

Commonly Used Forms

18+ Authorization for Release of Medical Information
Med. Authorization 18+.pdf
Adobe Acrobat document [130.9 KB]
Medical Records Release TO Our Office
Medical Release To Our Office.pdf
Adobe Acrobat document [85.8 KB]
Medical Records Release FROM our office
Medical Release From Our Office.pdf
Adobe Acrobat document [85.8 KB]

                  Fees for Personal Forms/Letters

Due to rising costs, we must now charge fees for completing forms and writing letters, such as those for school, sports or medical accomodations.

These taks require significant time and resources from our staff, and this change helps us maintain the high-quaility care your child deserves.  We understand this may be inconvenience, and we're committed to keeping fees reasonable while ensuring transparency.  Please contact the office with any questions.  Thanks for your understanding and continued trust in our practice.

 

Fees:

 

Forms (including physicals, camps, sports, travel and more)     $25.00

Letters                                                                                         $25.00

Same day fee (in addition to above)                                           $25.00

Legal forms/documents 1 page                                                   $50.00

Legal documents multiple pages                                                $100.00

 

*All paperwork requires a 48 hour minimum turnaround time

* We are unable to complete or generate any recommendation letters or other forms regarding family law or other legal matter without a subpoena or other official court document.

Physician's Report- Child Care Centers
Physician's Report- Child Care Centers.p[...]
Adobe Acrobat document [463.3 KB]
Health Exam for School Entry
Health Exam. for School Entry.pdf
Adobe Acrobat document [460.8 KB]
Authorization for Medications at School
Authorization for Meds. at School.pdf
Adobe Acrobat document [476.8 KB]
Youth Football Form
Pacific Youth Football League.pdf
Adobe Acrobat document [288.3 KB]

Mental Health Forms

PSC-17 Form
PSC-17 Youth.pdf
Adobe Acrobat document [57.8 KB]
PHQ9 teen
PHQ 9 Teen.pdf
Adobe Acrobat document [217.3 KB]
GAD-7
GAD7.pdf
Adobe Acrobat document [147.7 KB]
Vanderbilt Scales for ADHD
Vanderbilt initial 2025.pdf
Adobe Acrobat document [4.3 MB]
Dr. Dog says "Stay sun and water safe !"

Office Hours

By Appointment Only

 

Monday - Friday

9:00 am - 5:00 pm

 

Saturday

9:00 am - 12:00 pm

Conejo Children's Medical Group

558 N. Ventu Park Rd.

Suite D

Thousand Oaks, CA 91320

 

Phone  (805) 499-5525

Fax       (805) 499-5554

email: frontoffice@conejochildrens.com

 

Patient Portal:

https://health.eclinicalworks.com/conejochildrens

 

 

Print | Sitemap
© Conejo Children's Medical Group