Hi & Welcome to Raybon Pediatrics!

I have listed links to several forms for you, please print, complete, and return them to us by fax, photo, or email, or bring them in at your child’s first visit. Getting these forms as soon as possible will help to decrease your waiting time when you are at our office.

Additionally, you may register on our patient portal, but we will still need these forms for our records.

1. Release of Information:
Don’t worry about entering the healthcare facility, but please include in your reply who I should send it too and I will fill in the details.

2. HIPAA Privacy Policy Notice:
Please read and sign the last page and provide it to the office.

3. Patient Registration:
Demographics – This will help to get your child enrolled in our computer system. If you can email it back, that would be great, or you can bring it to the first appointment.
PMH – Past Medical History information. Don’t worry if you don’t know the answers to every question, just fill in what you know.

4. No Show Policy:
To accommodate our patients, it is important to be notified in advance if you are not going to make it to your appointment. Many times, we must turn patients away because there are no time slots available, only to have people not show up.

5.Finanicial Responsibility

6. Behavioral Health Policy:
If your child is being seen for ADHD, ADD, Anxiety, Etc. Please complete these forms and provide them to us.

I am looking forward to seeing you and your child soon!

Cindie Raybon, MD
Raybon Pediatrics
700 Zeagler, Ste 7
Palatka, FL 32177
ph: 386-385-8137
fax: 386-487-2113


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