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Award-winning Pediatric and Adolescent care from ages 0-24 years of age.
Open 365 days per year to suit your family's medical needs.

Blaine

7:30 am-7:00 pm Monday-Thursday, 7:30 am-5:00 pm Fridays, Weekends and holidays 9 am-10:30 am walk-in

Fridley

7:30 am-5:00 pm Monday-Friday

Appointments
763-333-7733
Business Office
763-333-7722
Fax
763-333-7711

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  • Home
  • Locations
  • Our Providers
  • FAQ
  • Links
  • Forms

Forms

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  2. Forms

List of forms available to download and complete prior to visit.

New Patient Forms

  • New Patient Packet

Demographic Forms

  • Under 18 years Demographic
  • Over 18 years Demographic

General Forms

  • Medical History
  • General Consent (Under 18 Years)
  • General Consent (Over 18 Years)
  • New Patient Survey
  • CTMC Notice of Privacy Practices
  • CTMC Price Transparency
  • Consent for minor without parent
  • Sports Physical Form
  • Community Resources

Release of Information Forms

  • Release of Information from CTMC
  • Release of Information to CTMC

Well-Child Forms/Info

  • Maternal Depression Survey 
    (Birth-6 months)
  • Mental Health Survey
    (ages 12 years and up)
  • Developmental Screening for Well-Child Visits
    (1 month -5 years)
  • Immunization/Vaccine schedule

Asthma Forms

  • Childhood Asthma Control Test (C-ACT)
    (ages 4-11 years)
  • Asthma Control Test (ACT)
    (ages 12 years and up)

ADD/ADHD/Behavioral Visits

  • Vanderbilt Parent Initial Form
  • Vanderbilt Parent Follow-up Form
  • Vanderbilt Teacher Initial Form
  • Vanderbilt Teacher Follow-up Form
  • Mental Health Survey

Depression/Anxiety Visits

  • Mental Health Survey
Love...Kindness...and Excellence.
  • More Information

Contact Info

  • Two Locations
  • Address:Fridley, MN
  • Address:Blaine, MNOpens in your application
  • Phone:763-333-7733
  • Email:info@www.childandteenmedicalcenter.comOpens in your application
Copyright 2023 - Child And Teen Medical Center
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Contact Us:

763-333-7733

Call us Anytime
24-hour on-call service

Walk-in urgent care

Weekends & Holidays - 9:00-10:30am-Blaine location only

Office Hours

Monday - Friday 8:00am - 4:30pm (Fridley)
8:00am-4:30pm (Blaine)
Saturday, Sundays and Holidays 9:00am-10:30am Blaine location only *special instructions at the door due to COVID-19