Patient Forms
Covid-19 vaccine available by appointment starting in June for children 12 years and older.
Registration
- Registration Form
- Initial History Questionnaire
- Acknowledgement of Electronic Submission of Prescriptions
- Patient Authorization For Use and Disclosure of Protected Health Information
- Release of Information and Release of Benefits
- Acknowledgement of Receipt of Notice of Privacy Practices
- Notice of Privacy Practices
Well Check Up
- ASQ 9 Month Questionnaire
- ASQ 12 Month Questionnaire
- ASQ 18 Month Questionnaire
- ASQ 30 Month Questionnaire
- M-Chat
- TB Risk Factor Questionnaire
- Lead Risk Questionnaire
ADHD
- Initial Parent Vanderbelt
- Initial Teacher Vanderbelt
- Vanderbilt Assessment Follow-Up Parent
- Vanderbilt Assessment Follow-Up Teacher
- Conners Parent
- Conners Teacher
- ADHD-RS-IV with Adolescent Prompts
Behavioral Health
Bard & Didriksen Pediatrics
2160 S. State Route 157, Suite B
Glen Carbon, Illinois 62034
Click here for driving directions.
Phone: (618) 692-1212
Fax: (618) 692-4875
After Hours Exchange:
(877) 552-1735
HOURS
(By Appointment Only)
Monday - Friday 8:30am to 5:00pm
Saturdays: Closed
Holiday Hours
Closed Memorial Day
Closed July 3rd & 4th
Closed Labor Day
Closed Thanksgiving
Open Friday After Thanksgiving
Closed Christmas Eve, Christmas, New Year's Eve & New Year's Day