Thank you for choosing Westerville Pediatric Specialists as your child's medical home, where we always provide a comfortable, caring environment so our patients and their families can feel at ease. We've included helpful items on this page to ensure you and your child's first trip to our office is productive, stress-free and enjoyable.
New Patient Forms
Welcome New Patients! Please click here to download all forms necessary for your child's first visit. Please complete and have the "Authorization To Seek Medical Care" form notarized where indicated prior to coming in for your child's appointment.
If you're preparing for your child's first visit, you can do a few things to help expedite the appointment. Please provide the following information when you arrive for your visit:
- Driver's license
- Insurance cards
- Complete immunization records
- Medical records from your previous pediatrician
- Registration Form
- Privacy Statement Form
- Privacy Consent Form
- Authorization to Release Protected Health Information Form
- Authorization to Seek Medical Care Form
- Health History Form
- Financial Policy Form
- Missed Appointments Policy Form
- Authorization for Co-Custodial Parent to Seek Medical Care
- Authorization for Step-Parent to Seek Medical Care
- Ohio Department of Health Child Medical Statement Form
- Ohio High School Athletic Association (OHSAA) Preparticipation Physical Evaluation form
- 2020-2021 Influenza Vaccine Form (for private insurance ie. Aetna, Anthem, United Health, Medical Mutual)
- 2020-2021 Influenza Vaccine Form (for Medicaid, Caresource, Molina, Buckeye Community, UHC Community, Paramount)
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it:
Our practice is working together to build life-long relationships between our staff and our patients by consistently providing our patients with compassion, excellence and value. To fulfill this mission, we are committed to:
- Improving the lives of the children we serve by providing quality care in a child-centered environment.
- Listening to our young patients and their families who we are privileged to serve.
- Guiding our patients along a path of optimal health and wellness.
- Continually pursuing excellence at all levels through continuing education.