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Forms and Policies

Former Patients

You may download and complete a request for our office to release medical records to yourself or a new medical provider. You may email the request to This email address is being protected from spambots. You need JavaScript enabled to view it. or mail the request to our office at the following address:

Phoenix Children’s Center
1661 E Camelback Rd Ste 170
Phoenix, AZ 85016

Request for medical records


Forms for New Patients

Forms for new patients include request for previous provider’s medical records, new patient information sheet, and health history form. These may be downloaded and completed prior to your appointment. Please bring these forms with you to your first appointment.

New Patient Information Form

Health History Form


Office Policies

Thank you for choosing The Phoenix Children’s Center, Ltd. as your health care provider. We are committed to providing the best possible care for our patients. We charge what is usual and customary for pediatricians in the area.

Co-payments, deductibles and services not covered by your insurance carrier are due on the date of service. We will file an insurance claim for you. You will receive a statement if your account has an outstanding balance. Any amount not paid within sixty days from the date of service by your insurance carrier will be deemed your responsibility.

A service charge of $30.00 will be assessed to your account per returned check.

A charge of $50.00 will be assessed to your account for missed appointments that are not cancelled 4 hours or more prior to the scheduled appointment time.

Failure to cancel appointments or pay for our services may result in dismissal from our practice.

A copy of our privacy policy is available below.

Privacy Policy