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Patient Info

Patient Forms

Appointment Check-In Documents

To expedite your appointment check-in, you may fill out the appropriate form(s) below to bring with you to your appointment. Most of the forms are available in a fillable PDF format with appropriate input fields.

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Ages & Stages Questionnaire

If your child was premature please call the office to find out the right ASQ to fill out since the age will need to be adjusted for premature infants. Please fill out age appropriate ASQ form for your child’s Well Child Check.

Release Forms


Check out what has been happening at Broomfield Pediatrics on our News page.


We accept most major medical insurances and self-pay for our services. 
We do not accept Kaiser, Medicare and UA Net (CU/BCBS).

Please remember to change the name of your PCP on your insurance card if you are transferring to our office, as required by your insurance plan. Newborns usually need to be added, in writing, to your insurance policy for coverage within 30 days of their birth. Deductibles and/or co-payments are expected at the time of service. A $20 fee could be added to the co-pay if it is not paid at the time of service. Other practice policies are available at the front desk.


Make a secure payment with our online payment tool.



We are currently located at:
3301 W. 144th Ave., Suite 200, Broomfield, CO 80023
This is located just east of Lowell on the North side of 144th avenue.

Frequently Asked Questions

A: For newborns: When you deliver your baby, let the hospital know who you’ve chosen as the baby’s primary doctor. If you are at Good Samaritan the nursery will call us, so that one of our doctors can come to see the baby. If you are at a different hospital, another pediatrician on-call for that hospital will come see the baby. You’ll need to call us to schedule the Newborn Check when you’re discharged from the hospital. Our doctors like to see the baby 24-48 hours after discharge.

For patients transferring in due to a move or insurance change: Our doctors would like all previous records in hand to review before we schedule a new Well Child or adult physical appointment. These can be requested with a “Record Release” form filled out at our office or with your previous physician. The records usually takes a minimum of 1-2 weeks to arrive. Previous records are not needed to be seen for a sick appointment.

A: Our office has a triage system in place to ensure that all patients needing to see a doctor will have a same-day appointment. Your call will be answered by the receptionist who will take down all the pertinent information for the nurse. The patient’s chart will be pulled and the nurse will return your call as soon as possible. Each triage nurse is trained to recognize those symptoms which require an immediate or same day appointment as well as offer the best home care advice if the patient does not need to be seen.

Phone Number: (303) 438-5522

A: Our doctors offer Meet & Greet appointments free of charge. These appointments are 15 minutes and give you the opportunity to meet the doctor and ask any questions you may have about the practice. No medical care is given during this time. We do not do Meet & Greet appointments for adult patients.

Request Meet & Greet Appointment Today Fill out the request appointment form. For the reason for visit select “Meet & Greet”

A: You will need to complete a “Release of Medical Information” form either at our office or with your new physician. The Release form must include the new physician’s address and the parent/legal guardian’s signature. Once we have received the form and the doctors have signed off on the transfer, our front office will copy and mail off the records. Please allow 2-4 weeks for your new office to receive the records. Records sent to another physician will be copied and mailed free of charge. Copies for your personal use or sent to multiple physicians will be charged $25 each.

A: In order for someone other than the parents to bring a child in for a sick appointment, a “Permission to Treat” form must be completed, signed, and in our office at the time of the patient’s appointment. Parents MUST accompany the patient for any Well Child appointments or consults.

Permission to Treat Form

A: We accept most insurance companies except for Kaiser, Medicare and UA Net (CU/BCBS). However, you should check with your insurance company. It is the responsibility of the patient’s parents/legal guardians to know what benefits and coverage of your insurance plan has.

For more on insurance visit our Insurance Page

A: Immunization records can be requested via phone, email or fax. We require up to one week for these requests.

Phone: (303) 438-5522
Fax: 303-438-5686

A: Our doctors can complete the vast majority of these forms if your child has had a Well Child Check within the previous 12 months. If your child has not had a check in over a year, s/he will need to be seen for a Well Child Check before the forms may be completed. You may mail or drop off the forms to be filled out or make a request via phone, email or fax.
We require up to one week for these requests.

A: Your copay is part of your contract with your insurance company which must be paid at the time of service. There will be a $20 charge for any copay that is not paid at the time of service.

A: Our doctors have medical staff privileges at

SCL-Good Samaritan Medical Center
St. Anthony’s North Health Campus
Children’s Hospital Colorado 

for newborn and pediatric patients.

Our group of physicians are credentialed with many of the major medical insurance plans. We offer medical care from your child’s nursery/newborn care all the way through adulthood.Please call our office to inquire if your medical insurance is on our list of carriers.