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New to the clinic?
These three forms cover most first-time requests. Everything else is grouped by visit type below.
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Registration
Register your child as a patient before your first appointment.
Open form (opens in a new tab) -
Appointment Request
Tell us what you need and when you’re available — we’ll confirm a time.
Open form (opens in a new tab) -
Online Referral
For physicians and health-care providers referring a patient to our clinic.
Open form (opens in a new tab)
All forms are submitted securely and are only available online. They help us compile an accurate medical history for accurate diagnosis and effective record-keeping.
Form library
Find your form
General Forms
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Open the Registration form (opens in a new tab)
Registration
New patients — register with the clinic before your first visit.
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Open the Appointment Request form (opens in a new tab)
Appointment Request
Ask for a visit or send the clinic a message.
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Open the Online Referral form (opens in a new tab)
Online Referral
For referring physicians and health-care providers.
History Forms
Choose the form that matches your child’s age, or the reason for the visit. Complete it before you arrive.
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Open the 0–4 Weeks history form (opens in a new tab)
0 – 4 Weeks
Newborn history for your first visits.
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Open the 1–12 Months history form (opens in a new tab)
1 – 12 Months
Infant history for babies under one year.
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Open the 1–4 Years history form (opens in a new tab)
1 – 4 Years
Toddler and preschool history.
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Open the Elementary School history form (opens in a new tab)
Elementary School
School-age children.
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Open the High School history form (opens in a new tab)
High School
Teens and adolescents.
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Open the Behaviour history form (opens in a new tab)
Behaviour
For visits about behaviour or attention concerns.
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Open the Breastfeeding first visit history form (opens in a new tab)
Breastfeeding — First Visit
For your first appointment at The Breastfeeding Clinic.
Follow-Up Forms
For return visits — complete before each follow-up appointment.
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Open the Breastfeeding follow-up form (opens in a new tab)
Breastfeeding Follow-Up
Return visits to The Breastfeeding Clinic.
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Open the ADHD follow-up form (opens in a new tab)
ADHD Follow-Up
Ongoing ADHD care and medication review.
Vanderbilt Assessment Scales
Used to assess attention and behaviour. Both versions are usually needed — one from a parent, one from a teacher.
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Open the Vanderbilt parent assessment scale (opens in a new tab)
Vanderbilt Scale — For Parents
Completed by a parent or guardian.
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Open the Vanderbilt teacher assessment scale (opens in a new tab)
Vanderbilt Scale — For Teachers
Completed by your child’s teacher.
Screening Forms
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Open the developmental screening checklist (opens in a new tab)
Developmental Screening
Nipissing District Developmental Checklist — milestones by age.
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Open the hearing screening form (opens in a new tab)
Hearing Screening
Complete if you have concerns about your child’s hearing or speech.
No forms match that search. Try a different word, or contact the clinic and we’ll help you find it.
Need help with a form?
Call or text the clinic during office hours and we’ll walk you through it.