southside header




Printable Forms

Please feel free to print these forms and present them

to the receptionist upon arrival.


wilgus Dr. Carrie Wilgus

Dr. St Jacques

Dr. Abby



Emily Sydloski

Physician Assistant


Ashley Gielarowski

Nurse Practitioner



Southside Pediatrics Office policies

Allergy shots in the Office Policy

"Family Medical Leave Act" Policy and Fee

Patient Center Medical Home Agreement

Southside Pediatrics Patient Information and Registration form *

HIPPA Notice of Privacy Practices

Patient Consent to Use and Disclose *

Medical History Questionnaire *

Consent to Share Medical Information *

MCIR Immunization form *

Refusal to Vaccinate Form

Immunization Schedule

Transferring to Southside Pediatric Practice

Transferring from Southside Pediatric Practice

School Physical Form for Most Local Schools

PCMH Agreement Signature Page *


Business Hours: Monday-Friday 7:30am to 5pm

Phone: (269) 818- 1020, Fax: (269) 818-1266 After Hours Answering Service: 269-945-9567

Web Page Copyright Southside Pediatrics, 300 Meadow Run Drive, Hastings, MI 49058