MENU Forms Listed below are the forms needed for new patients or to transfer. Click on needed form and open. Patient Information Form Preferred Pediatrics Policies HIPAA Privacy Practice Notice Release of Information Medical Records Release Form Office Policies Preferred Pediatrics at Lee's Hill 10600 Spotsylvania Avenue Fredericksburg, Virginia 22408 Phone: (540) 604-9500 Fax: (540) 604-9501 Directions Preferred Pediatrics at Snowden 331 Park Hill Drive Fredericksburg, Virginia 22401 Phone: (540) 368-8091 Fax: (540) 368-8095 Directions Preferred Pediatrics at the Courthouse 9755 Courthouse Road, Suite 101 Spotsylvania, Virginia 22553 Phone: (540) 898-9680 Fax: (540) 898-9699 Directions © 2021 My Preferred Pediatrics All Rights Reserved

MENU New Patient Paperwork (First Visit) Please print, complete and bring all forms below to your first appointment or fill out forms online where available. Please also be prepared to provide a parent and/or guardian's photo identification as well as the patient's insurance card. Patient Information Sheet Preferred Pediatrics Policies Information Release Form If you need assistance accessing any of these forms, please contact us. Preferred Pediatrics at Lee's Hill 10600 Spotsylvania Avenue Fredericksburg, Virginia 22408 Phone: (540) 604-9500 Fax: (540) 604-9501 Directions Preferred Pediatrics at Snowden 331 Park Hill Drive Fredericksburg, Virginia 22401 Phone: (540) 368-8091 Fax: (540) 368-8095 Directions Preferred Pediatrics at the Courthouse 9755 Courthouse Road, Suite 101 Spotsylvania, Virginia 22553 Phone: (540) 898-9680 Fax: (540) 898-9699 Directions © 2021 My Preferred Pediatrics All Rights Reserved

MENU Medical Records Release Form Click here to download and print form. Please note that this form must be completed in full and the signature must match the signature on file for the patient's parent or legal guardian. Please allow up to 14 days for processing. If you need assistance accessing this form, please contact us. Preferred Pediatrics at Lee's Hill 10600 Spotsylvania Avenue Fredericksburg, Virginia 22408 Phone: (540) 604-9500 Fax: (540) 604-9501 Directions Preferred Pediatrics at Snowden 331 Park Hill Drive Fredericksburg, Virginia 22401 Phone: (540) 368-8091 Fax: (540) 368-8095 Directions Preferred Pediatrics at the Courthouse 9755 Courthouse Road, Suite 101 Spotsylvania, Virginia 22553 Phone: (540) 898-9680 Fax: (540) 898-9699 Directions © 2021 My Preferred Pediatrics All Rights Reserved

MENU New Patient Information Please select an article from the list below and click to view. Preferred Pediatrics at Lee's Hill 10600 Spotsylvania Avenue Fredericksburg, Virginia 22408 Phone: (540) 604-9500 Fax: (540) 604-9501 Directions Preferred Pediatrics at Snowden 331 Park Hill Drive Fredericksburg, Virginia 22401 Phone: (540) 368-8091 Fax: (540) 368-8095 Directions Preferred Pediatrics at the Courthouse 9755 Courthouse Road, Suite 101 Spotsylvania, Virginia 22553 Phone: (540) 898-9680 Fax: (540) 898-9699 Directions