Najem ADHD Clinic

New Child ADHD Patient /
Family And Insurance Information Form

Today is Friday/23/03/2018



What is your child's gender?


*Attenion: If you do not include a proper home address in the fields below, you're form will be discarded/deleted immediately. Answers such as n/a are not acceptable answers. We need a complete and accurate address to be able to bill you for our services, as well as creating a medical record for you.

Patient's Parental Information

Father's Name


Father's D/O/B


Father's Martial Status


Father's Address


Father's Email

Father's Phone




Mother's Name


Mother's D/O/B


Mother's Address


Mother's Email

Mother's Phone




* Please read the following statements and check the boxes if you agree.

Parent Name or Representative (if guardian).


Meaningful Use Form




This office may ePrescribe (send prescriptions electronically to your pharmacy) and view my external history prescriptions (prescriptions written by other doctors).


How would you describe the patient's ethnicity? If you are uncomfortable answering the questions, you may select "Decline to answer".

I authorize Vinaya K. Gavini MD to release any medical records when I request them to be shared.


Notice of Privacy Practices

I have read and agree with the above notice of PRIVACY PRACTICES.







DSM-IV Questionaire (Please select yes or no for each symptom)


Symptoms of Hyperactivity and Impulsivity Symptoms: Please be sure to select Yes or No for each question.


Symptoms of Innatenttion: Please be sure to select Yes or No for each question.


Clinic Hours

Mon: 8am-6pm
Tues-Thurs: 12pm-6pm
Fri: 8am-2pm
Sat: 8am-12pm

Najem ADHD Clinic

26850 Providence Parkway
Suite 300
Novi, Michigan
(248) 348-4200