Mandarin Pediatrics Forms and Policies

Before your appointment with us, quickly and conveniently access patient forms from Mandarin Pediatrics.

To view the forms listed below, you will need Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.

General Forms

Authorization Form for Non-Caregiver

ADHD forms and policies

We recommend calling 7 days in advance in order to account for vacations, holidays and weekends.

Please allow 3 days for the refill of ADHD medication.

Your child requires a biannual visit every 6 months for follow-up and evaluation of their ADHD. No medications will be refilled if past this date. Your child’s annual well-visit take the place of one of these.

*As of January 1st, 2018 we will no longer be seeing ADHD patients at an interval of every 6 months. In accordance with American Academy of Pediatric recommended guidelines, we will start seeing these patients every 3 months for regular follow up. 4 total visits in a year, with 3 as follow-up appointments and one with the annual well visit. This is also in compliance with federal DEA mandates. We understand that this is a deviation from our past practices, but national standards of care have changed, and as always, we strive to provide the best care for our patients and their families.

Vanderbilt ADHD Rating Scales: Please print forms (one for each parent and one for each teacher) and bring the appropriate forms with you to your visit. Remember to allow for time for completion by both parents and teachers. You can also give a Teacher Form to your child’s coach or instructor.

Autism Screening

The AAP recommends general screening to be performed at 18-24 months of age.

M-CHAT: This is a validated tool for autism evaluation. Please print out and fill out the 2nd page for your child’s 18 month well visit.

M-CHAT screening tool

After Hours policy

Please call during regular office hours in order to: Make appointment, address non-urgent concerns, and refill medications.

After hours and on the weekend, your urgent phone calls are answered by Tele-Care, an experienced Pediatric Nurse triage line. One of our providers is always available to assist them with addressing your concerns.

Lead Screening

The AAP and the Florida Department of Health recommends general lead screening in the following fashion:

1. Blood testing at 12 and 24 months of age.

2. Blood testing of any child 3-6 years of age that meet any of the following criteria:

  • Children living in a high risk area (Duval County is one of them).
  • Children with siblings with lead poisoning or living in a building where someone had lead poisoning.
  • Children receiving Medicaid.
  • Children with delayed cognitive development.
  • Children who are adopted from outside the U.S., immigrants, or refugees.
  • Children in foster care.
  • Children who answer “yes” or “unknown” to any questions on the following questionnaire.

3. Questionnaire screen for all children under the age of 6 at annual visit.

Lead Poisoning Risk Assessment Questionnaire: This is a validated tool for lead screen and evaluation. Please print out and fill out the 2nd page prior to your child’s annual well visit.

School Forms-Florida Department of Health:

1. Preparticipation Physical Form. Required for participation in school sports. Bring to visit with the first part filled out by caregiver.
2. School Entry Form is the physcial form required for entry to schools, preschools, and daycare. The first part is filled out by caregiver, and the second by the examining provider. An immunization record will be given to you at the time of the visit.

Call Us At (904) 268-7701