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Forms and Medical Records

Patient Forms

These forms can be completed prior to your scheduled visit.  A copy will be available in the office as well.

School Forms

Please fill out as much of the form as possible prior to your child’s well visit and bring it with you or email prior to the visit.  Please confirm that the correct form is completed,
not all schools accept the general DC, MD or VA forms.

Please bring your sports or camp physical forms with you to your well visit appointments with your portion completed in full. Please note that the forms require your authorization via signature on the page, otherwise we are not able to provide it to your school. If your child has had a physical in the past 12 months, the form can be completed based on that physical. There is a $25.00 for each school/sports participation/camp form.

Please schedule a pre-surgical visit If your specialist requires a preoperative clearance by your pediatrician.  The surgeon will provide you with a form for us to fill out.  The information from your child's well visit or a recent acute visit cannot be used to complete a pre-operative form.  

We will be happy to provide you with a school or work excuse if your child was seen at our office. We cannot provide excuses for dates we did not see your child.  We also cannot provide excuses for visits to emergency rooms, urgent care facilities, or other physician’s offices.

Copies of updated vaccination records can be provided on the day that the vaccination is received.  Otherwise, please allow 3 business days and inform the office staff of the preferred method of receipt (pick-up, email, standard mail).

Please complete a form for release of medical information if you would like to have your record copied in its entirety for personal use or transfer to another practice.  Allow 1-2 weeks for to record to be copied and contact the office to confirm its readiness prior to pick-up. A base fee of $25 will be charged for copying the medical record.  If you require other medical information in the patient’s chart such as clinic notes or previous lab values, please email specifying the exact dates and nature of the information or complete an authorization in person.   Allow 3-5 business days for response. Depending on the amount or nature of the information, the records may have to be picked up in person at our office during business hours.   

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