CPM encourages all patients to print and complete the forms prior to their visit. Please arrive 15 minutes before your appointment; this time will be used to complete any additional forms that are not posted on our website. You may also take this time to ask any further questions in regards to your appointment.
- CPM Financial Policy
- AAP- HIPPA- Notice Of Privacy Practices
- Newborn Insurance Policy
- Vaccine Policy
- Lactation Consult Information
- Testing & Insurance Policy
- School, Sports & Camp Forms Policy
- Welcome to Center for Pediatric Medicine Brochure
- Patient Registration Form
- Patient Registration: Spanish
- Patient Registration: Portuguese
- Confidential Communication Authorization
- Signature of Notice of Privacy Practices
- No New Husky Patients
Health Care Assessments
- 9 Month Questionnaire
- 22 Month Questionaire
- 30 Month Questionnaire
- Health Assesment Record 10 Years & Up
Health Care Screenings
- Designation of Authorized Representative
- Change of Information Form
- 18 Year Old PHI Release Form
- PHI Release Form
- Authorization for Release of Health Information:Transfer of Patient Records-Into the Practice
- Authorization for Release of Health Information:Transfer of Patient Records -Out of the Practice
M-CHAT QUESTIONNAIRE (Autism Screening)
M-Chat (the Modified Checklist for Autism in Toddlers) is a list of 23 questions used to screen toddlers for autism at their 18 and 24 month physical exams. Please click here for a printable copy of the questionnaire, which you can complete and bring with you at the 18 and 24 month appointments.
Fluoride test kit Information It is important to have your well water tested for fluoride content. Fluoride is naturally occurring in groundwater and therefore may be in your well water in trace amounts, adequate amounts or even excessive amounts than the recommended level. It is wrong to assume that well water has no fluoride. The best way to be sure your child is receiving the appropriate amount of systemic fluoride is to have your well water tested for fluoride content. Please click here for the UConn fluoride testing information sheet.
Classes & Events
Birth & Beyond
CPM offers prenatal newborn classes. Classes have limited space each month. Please call our main office today to request our availability.
New Patient Meet and Greets
Come tour our office and learn more about the Center for Pediatric Medicine. Please contact our main office at 203-790-0822 to book an office visit tour.