Pediatric Medical History Form
This is an electronic version of Pohala Clinic PC's Pediatric Medical History form. This should be completed and submitted prior to your child's first appointment at Pohala. This form will take approximately 10-20 minutes to complete. Note: This must be completed no later than 1 business day prior to your child's appointment. The answers you provide here are private, and will be used only in regards to your child's healthcare. These answers are protected under HIPAA.
Sign in to Google to save your progress. Learn more
Email *
What is the date of your child's appointment? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pohala Clinic. Report Abuse