Child Intake Form

Please print and complete this form only after you have scheduled an appointment for your child with Dr, Bartlett.  The information that you include in your responses on this form will provide Dr. Bartlett with information about your child’s development, health status, and behavioral issues, and will guide her in conducting her evaluation.

To fill out this form online, click the Download link on the left.  When you are finished with the portion that you can complete online, print it, and complete the circled items by hand.

Download (PDF, 87KB)

Do not use this form in an attempt to schedule an appointment.  Again, please  submit this form only after you have already scheduled an appointment with one of our Providers.  Forms submitted without a scheduled appointment will not be reviewed, and you will not be otherwise contacted.

All health and health-related information contained within this WPAPC website is intended to be general in nature and should not be used as a substitute for a visit with a health care professional. No information provided in this site may be considered medical advice. The information may not be relevant for your individual situation and may be misinterpreted. WPAPC assumes no responsibility for how you use information obtained from this site. Before making any decisions regarding your health care, ask your personal physician.

Please be aware that most information transmitted over the Internet is not secure; thus, confidentiality cannot be guaranteed. Information of a confidential, proprietary or privileged nature should not be sent electronically to WPAPC. Any patient information transmitted to our site will be treated as non-confidential. Personal medical information should never be sent to our website.