Patient Forms

New Patient Forms

Patient Welcome Packet

Click to download
New Patient Welcome Packet

Authorization for Release of Medical Information

Patient and Family Demographic

Consent To Treat

Click to download
Consent To Treat

Initial History Questionnaire

Patient Responsibility Form

Click to download
Patient Responsibility Form

General Forms

Notice of Privacy Practices

Click to download
Notice of Privacy Practices

Privacy Policy Statement

Click to download
Privacy Policy Statement

Security Policy Statement

Click to download
Security Policy Statement

Authorization for Release of Medical Information

Consent to Treat

Click to download
Consent To Treat

Initial History Questionnaire

Helpful Charts

Tylenol & Ibuprofen Dosing Charts

Location & Hours

15290 Summit Avenue
Suite B
Fontana, CA 92336

Phone: (909) 225-1900
Fax:     (909) 663-9070
Email: goldstarpedsfontana@outlook.com

Office Hours:
Mon Wed Fri 8:00am – 5:00pm
Tues Thurs   9:00am – 6:00pm