top of page

Patient Forms

Document with Pen

ASQ - 9 months

Ages & Stages Questionnaires® - 9 months​

ASQ - 18 months

Ages & Stages Questionnaires® - 18 months​

Financial Policies

Authorization for assignment of benefits

Interpreter Services

Interpreter Services Form

Medical Record Release from ICC

Authorization for ICC to release medical records

Medical Record Release to ICC

Authorization to disclose information to ICC

New Patient

First time patient information form

Nondiscrimination

Notice of Nondiscrimination Form

Permission to be Seen

Permission for children to be seen with non-parent/guardian

Privacy Notice

Notice of Privacy Practices

Alabama High School Athletic Association Physical Form

Please complete page 1 prior to submitting physical form to our office

Standard Office Forms
Translated Into Spanish

Spanish

ASQ - 9 months

Ages & Stages Questionnaires® - 9 months

Ages & Stages Questionnaires® - Cuestionario de 9 meses

ASQ - 18 months

Ages & Stages Questionnaires® - 18 months

Ages & Stages Questionnaires® - Cuestionario de 18 meses

Financial Policies - Spanish

Authorization for assignment of benefits

AUTORIZACIÓN PARA ASIGNACIÓN DE BENEFICIOS

Y

AUTORIZACIÓN PARA DIVULGAR O RECIBIR INFORMACIÓN MÉDICA

Medical Record Release from ICC - Spanish

Authorization for ICC to release medical records

Autorización para divulgar información médica protegida

Medical Record Release to ICC - Spanish

Authorization to disclose information to ICC

Autorización para divulgar información médica protegida

New Patient - Spanish

First time patient information form

Por favor escriba todos los pacientes que se encuentran actualmente en nuestra práctica.

Nondiscrimination - Spanish

Notice of Nondiscrimination Form

La discriminación es ilegal

Permission to be Seen - Spanish

Permission for children to be seen with non-parent/guardian

PERMISO PARA QUE NIÑOS SEAN VISTOS POR MEDICO CON OTRA PERSONA A PARTE DE PADRES/GUARDIAN

Privacy Notice - Spanish

Notice of Privacy Practices

AVISO DE PRÁCTICAS DE PRIVACIDAD

Quick Links

  • Infants’ & Children’s Clinic Facebook Link
  • Instagram

Contact  |  Hours

Infants’ & Children’s Clinic, PC

421 W College St  |  Florence, AL 35630

ph 256-764-9522  |  fax 256-764-1139  

Monday - Friday:  8:00am - 4:30pm

Saturday:  scheduled appointments only

Well Child Clinic

1605 Mockingbird Ct  |  Florence, AL 35630

   ph 256-764-9522  |  fax 256-764-1139

Monday - Friday:  8:00am - 4:30pm

Closed for Lunch:  Noon - 1:10pm

Directions

© 2025 Infants’ & Children’s Clinic, PC

website managed by Signature Studios

bottom of page