All female patients should fill out this form.

• Female Patient Form

All Male patients should fill out this form.

• Male Patient Form

Only women visiting our offices for termination of pregnancy should print and fill this form out.

• Termination of Pregnancy

Pediatric Patient Forms.

• Patient History
• Family History
• Child History
• Pediatric Alliance Privacy Statements
• 12-18yr old Confidentiality Statement
• Parent-Guardian Letter
• Pre-Participation Physical Evaluation
• Influenza Vaccine Information
• FluMist Consent

HIPAA Privacy Notice

Have a Question? Dr. Pendergraft is available to answer your sexual health related question by
e-mail 24 hours 7 days a week at Drpendergraft@gmail.com