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Call for Appointment,
24/7 Nurse Advice


Find Our Clinics
in Central Oregon

COPA Patient Forms

Here you’ll find the forms we use to help expedite your child’s care. If you have any questions, please feel free to call us. You’re welcome to download the forms and fill them out before you arrive for your appointment.

New Patients to COPA

Well-Child Check Questionnaires

Release Medical Records TO COPA FROM another Provider

Release Medical Records FROM COPA TO another Provider

Sports Physical Forms Approved by the OSAA

Behavioral Healthcare Vanderbilt Forms

CONSENT BY PROXY FOR MEDICAL TREATMENT | A parent or appointed guardian is required to accompany their child, 14 years or younger, to the child’s annual well-exam and for any vaccinations. The provider will inform the parent or guardian about the health of the child, discuss issues important to the patient, and in some cases COPA must receive permission to administer care. A person authorized by the parent or guardian to provide consent for medical treatment may accompany the child for sick visit only, however, the following form must be completed and delivered to COPA for treatment to occur.   Consent by Proxy for Medical Authorization


Bienvenido a COPA

Autorizacion Para Solicitar Registros Medicos De Fuera

CONSENTIMIENTO DE PROXY PARA EL TRATAMIENTO MÉDICO | Se requiere que un padre o tutor designado acompañe a su hijo, de 14 años o menos, al examen de bienestar anual del niño y para cualquier vacuna. El proveedor informará al padre o tutor acerca de la salud del niño, discutirá temas importantes para el paciente y, en algunos casos, COPA debe recibir permiso para administrar la atención. Una persona autorizada por el padre o tutor para proporcionar el consentimiento para el tratamiento médico puede acompañar al niño para una visita por enfermedad solamente, sin embargo, el siguiente formulario debe completarse y entregarse a COPA para que se realice el tratamiento.  Autorizacion Por Consentimento Del Representante

©2017 Central Oregon Pediatric Associates | COPA is the largest provider of health care for infants and children in Central Oregon.
Open 365 days to serve our community with three locations, expanded hours and 24/7 Nurse Advice.