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Somerset Pediatrics

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Forms & Downloads

Click on a link below to be taken to the section it describes.

Information for New & Established Patients

For new patients transferring to our practice, please complete the Record Transfer Form and send to your current pediatrician. We must receive the records prior to scheduling an appointment for your child or children. For assistance or questions, please contact the office at: 860-652-3325.

Patient Registration Form Please complete (for each child) and bring to your first visit
Family Contact Information Form Download the family contact information form here
Record Transfer Form To transfer records, fill out this form
Well Child Exam Schedule with Screenings View a list of screening exams performed with your child’s well visit. We encourage you to check with your insurance company regarding coverage of these screening exams prior to your visit.
Tylenol and Advil Dosing Chart Medication dosing by weight for newborns through age 12
Husky Application & Renewal Form Click here to see if you qualify for participation in the Husky Health Program
ProHealth Application for Financial Hardship Uninsured? Having difficulty paying your bill? Print and complete this application to see if you qualify for reduced billing amounts for our services

For New Parents

Fever Facts Information for new parents about fevers in newborns and infants
Tylenol and Advil Dosing Chart Medication dosing by weight
Things to Have On Hand A list of Items to have at home for your baby
Salt Water Nose Drop Recipe To ease nasal congestion
Vitamin D Recommendations Breastfed babies should receive Vitamin D
Car Safety Seat Checkup

Vaccine Information

Somerset Pediatrics Immunization Schedule
After The Shots
Too Many Vaccines? What You Should Know
Vaccine Ingredients
Vaccines—The Facts
Thimerosal—What You Should Know
Vaccines and Autism—What You Should Know
CDC Immunization Schedule—Birth to Age 6
CDC Recommended Immunizations—Ages 7–18
Vaccine Information Sheets Click to be directed to the CDC Published VIS Forms

For Parents of Infants

Well Child Exam Schedule and Screenings When to bring your infant in for well child exams
A Guide to Introducing Solid Foods
Tylenol and Advil Dosing Chart Medication dosing by weight

For Parents of Toddlers

Toilet Training Guidelines
Food for Thought The value of family meals
Toddlers Feelings of Security Depend Upon Parental Authority Parental authority is the essence of a child’s security
Tylenol and Advil Dosing Chart Medication dosing by weight

Well Visit Handouts from Birth to Age 4

Your Newborn Infant
Your Newborn—The First Two Weeks
Your Infant at 2 Months
Your Infant at 4 Months
Your Infant at 6 Months
Your Infant at 9 Months
Your Baby at 1 Year
Your Toddler at 15 Months
Your Toddler at 18 Months
Your Toddler at 2 Years
Your Toddler at 2 1/2 Years
Your 3-Year Old
Your 4-Year Old

School, Daycare, & Camp Forms

Early Childhood Health Assessment (Yellow Form)
Health Assessment Form—Ages 5 & Older (Blue Form)
CT Authorization to Administer Medication For daycare, school, and camp
GHS Sports Form 2014—2015
CT Youth Camp Health Exam Form
Boy Scouts Camp Health Form Click here to visit the Boy Scouts forms site
Girl Scouts Camp Health Form Click here to visit the Girl Scouts forms site
Camper Health History Form—Part 1
Camper Health Care Recommendations—Part 2

ADD/ADHD Information & Forms

Medication Policy Information on when and how to request a medication refill
Vanderbilt Parent Initial Assessment Form Both parents should complete this form
Vanderbilt Parent Follow-Up Assessment Form
Vanderbilt Teacher Initial Assessment Form Have as many teachers as possible complete the form
Vanderbilt Teacher Follow-Up Assessment Form

For Parents of Adolescents

Talking with Your Teen—Tips for Parents
Drug Abuse Prevention Starts with Parents
Drug Chart
A Parent’s Guide to Teen Parties
Next Stop, Adulthood—Tips for Parents

Well Visit Handouts for Ages 5 Through 21

Your 5- and 6-Year Old Child
Your 7- and 8-Year Old Child
Your 9- and 10-Year Old Child
For Parents—The Early Adolescent, Ages 11–14
For Parents—Your Adolescent, Ages 15–17
My Handout—I’m Between 11 and 14 Years Old
My Handout—I’m Between 15 and 17 Years Old
My Handout—I’m 18 and Older

Nutrition Information

Healthy Me (click to visit website)  
Calorie Boosters for Weight Gain  
My Plate—Tips, Recipes and Nutritional Information (click to visit website)  

Illnesses & Conditions

Upper Respiratory Infections and Cough Croup
Urinary Tract Infections Clean Catch Urine Instructions
Warts Pinkeye and Styes
Concussion Information Diarrhea
Home Care for Vomiting Irritable Bowel Syndrome
Lymph Nodes or Swollen Glands Seasonal Allergies in Children
When Your Child Has Fifth Disease Bronchiolitis
Winter Wise Summer Safety Tips