Pediatric Practices of Northeastern PA
Providing quality care in Wayne and Pike Counties.
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Healthcare Medical Forms

Choose from the following healthcare forms so we can better assist you.

Form to request transfer of records TO another healthcare provider

Form to request records FROM another healthcare provider

Form to give a non-custodial person permission to bring your child to our office

Form for parent or legal guardian consent to treat the child in our office

Emergency Information Form for Special Needs Child

New patient registration information

Financial Policy Form

Our Credit Card On File Policy

Please fill out the following forms and bring them to your next visit.

Credit Card on File Authorization Form & Letter (PDF)

Credit Card on File Policy Deductible Information(PDF)

Credit Card on File Policy Q&A (PDF)





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