Patient Forms
READ OUR BLOG POST ON COVID-19
We will be closed on Saturdays and our hours may vary due to COVID-19.
FLU SHOTS ARE IN FOR PATIENTS WITH PRIVATE INSURANCE
Call 618-692-1212 for an Appointment.
- Registration Form
- 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
- Initial History Questionnaire
- ADHD-RS-IV with Adolescent Prompts
- ASQ 9 Month Questionnaire
- ASQ 12 Month Questionnaire
- ASQ 18 Month Questionnaire
- ASQ 30 Month Questionnaire
- The Burns Anxiety Inventory
- The Burns Depression Checklist
- M-Chat
- TB Risk Factor & Lead Risk Questionnaire
- Vanderbilt ADHD Parent Rating Scale
- Vanderbilt Assessment Follow-Up Parent
- Vanderbilt Assessment Follow-Up Teacher
- Anxiety Scared Child
- Initial Parent Vanderbelt
- Conners Teacher
- Teenscreen
- Conners Parent
- Pediatric Symptom Check List Parent
- Pediatric Symptom Check List
- Initial Teacher Vanderbelt
- Anxiety Scared Parent
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