Forms and Resources

Forms

Medical Records
Release of Medical Records FROM St Teresa Pediatrics
Release of Medical Records TO St Teresa Pediatrics

Referring Providers
Referral from Specialty Providers to ABC and Nephrology Clinics
Referral from PCPs to ABC and Nephrology Clinics
Please fax completed forms to 314-500-5683 (LOVE)

Missouri Sports and Daycare
Missouri sports physical form

Please fill out page 1 and 2 prior to your appointment.
Missouri Return to Play after Concussion Form

Missouri daycare form
Please give our office THREE business days to fill out this form for your child.
Immunization records for established patients can be downloaded through the patient portal.

Non-parental consent to medical care and treatment

Authorization to Release Information to Family Members

ADHD Testing, INITIAL Vanderbilt Forms

ADHD Follow-up Assessment, Parent and Teacher Vanderbilt forms
Download and complete

Childhood Asthma Control Test
Download and complete

Asthma Action Plan
Download and complete

FARE Food Allergy Action Plan

How to use an Aerochamber with mask

How to Use an Aerochamber with Mouthpiece

Family Media Use Plan

The Survey of Well-being of Young Children
Childhood Anxiety Screen by Parent Report (spreadsheet)
Childhood Anxiety Screen by Child Report (spreadsheet)
Ages & Stages Questionnaires (please print out results and bring to your checkup)
CDC’s Developmental Milestones
PBS For Parents – Child Development Activities

St Teresa Pediatrics Office Policies

Missouri state high school activities association has very important information on staying safe while playing sports, including concussion.

Information on Missouri WIC
Missouri is a high-risk state for childhood lead poisoning. More info here.

How to fit a bike helmet
Safe Kids Worldwide website
Dangerous Baby Products to Avoid
Consumer Product Safety Commission

Heavy Metals in Baby Food
For Picky Eaters!
Anti-reflux diet for children and teens (not babies)

KidsHealth website
BabyCenter website
Skin Conditions in Children
How to use nasal spray in kids
How to do a NeilMed sinus rinse

For Marriages

Help for Troubled Marriages
Retrouvaille – a lifeline for marriages