Patient Forms
New Patient Forms
Patient Welcome Packet
Click to download
New Patient Welcome Packet
Authorization for Release of Medical Information
Click to download
Authorization for Release of Medical Information
Patient and Family Demographic
Click to download
Patient and Family Demographic
Consent To Treat
Click to download
Consent To Treat
Initial History Questionnaire
Click to download
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
Click to download
Authorization for Release of Medical Information
Consent to Treat
Click to download
Consent To Treat
Initial History Questionnaire
Click to download
Initial History Questionnaire
Helpful Charts
Tylenol Dosing Charts
Click to download
Tylenol Dosing Charts
Ibuprofen Dosing Charts
Click to download
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