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Talk with a health educator - MaineHealth Learning Resource Center

Western Maine Pediatrics  


Please allow 3-5 business days for any forms that require a physician's signature. 

If you find that you need to transfer your child's care to another practice please contact our office by phone at 207-743-8766 or stop by our office and we will assist you in completing the appropriate paperwork.   

General Forms
Authorization to Release or Obtain Protected HealthCare Information (need to be completed annually or if requesting records)
Consent to Treat Form (To be completed at every visit)
Notice of Health Information Privacy Practices 

New Patient Forms  
Our Brochure 
Welcome Letter 
New Patient Intake Form 
Patient Demographic Form 
Missed Appointment Policy

Routine Asthma Visit Forms
Asthma Control Test Form (4 years of age and younger) 
Asthma Control Test Form (5 years of age to 11 years of age)  
Asthma Control Test Form (12 years old and older) 
Peak Flow Meter Instructions 
Peak Flow Diary 
Inhaler with Spacer Instructions 
Spacer with Mask Instructions 

Attention Deficit Hyperactivity Disorder Forms 
Vanderbilt Teacher Form  
Vanderbilt Parent Form



Symptom Checker


181 Main Street, Norway, Maine 04268 | (207) 743-5933, TTY (for the hearing impaired): (207) 743-1597