Patient Forms

Welcome to our practice! 

We have included forms that you may download and complete prior to your office visit.  Ask our staff when you are making an appointment if you will need any of these forms. Any student participating in high school sports or band will need a school sports physical form completed yearly - ideally at the annual physical.  

  • Patient Registration Form [pdf]
  • School Medication  Authorization [pdf]
  • School Sports Physical Form [pdf]
  • Parental Consent  to Treat [pdf]
  • Release of Records (Records Request) [pdf]
  • New Patient History Form [pdf]

We also have several forms and questionnaires available on CHADIS.com.  If you have not registered on CHADIS,  please contact our office for the invitation code.  We also have the following questionnaires available if you are directed to download and complete these forms prior to your visit.

  • NICHQ Vanderbilt Parent Form [pdf]
  • NICHQ Vanderbilt Teacher Form [pdf]

In order to view or print these forms, you will need Adobe Acrobat Reader installed.
Click here to download it.

Contact Us

If you are an established patient, please use the portal.  Click below to go to the portal website:  If you are not already registered for the portal, you may call the office to sign-up.

Lighthouse Pediatrics Portal

You may use the form below to request NON-urgent appointments.  Please do not include personal health information.

Our Location

Office Hours
Monday:8:30 AM - 5:00 PM
Tuesday:8:30 AM - 5:00 PM
Wednesday:8:30 AM - 5:00 PM
Thursday:8:30 AM - 5:00 PM
Friday:8:30 AM - 5:00 PM
Saturday:Closed
Sunday:Closed