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A number of forms normally requested are listed below. For school and camp forms there is a $10 fee. 

For a copy of the medical record there is a $20 fee per child, maximum of $50 per family.

Please complete all parental portions of forms prior to the visit. This allows the medical provider to review this information when completing the requested forms. Please hand any forms to the front desk staff when checking in. Do not hand forms to the medical staff during the visit itself. This both slows down the process of the visit and completion of the form.

Registration Forms

Release of Information Form

(consent to communicate with outside providers)

18yr+ HIPAA Release

For Patients age 18 and older: HIPPA Release

Flu Vaccination Forms

Medical Records

Request records from your old pediatrician to give to us

Use this form to request that your previous practice release your medical records and vaccine history to us so that we can better provide care to your child.

Do you need medical records from us?

Use this form if you are moving or leaving our practice and/or would like copies of your medical and vaccine records for your own future use.

School Forms