School / Camp Form Request (for current patients only)
Complete and submit the information below to request a computerized printout of your child(ren)'s Health Summary or "school form". This includes immunization & medical history, as well as most recent physical. It provides all the information required by camps, schools, or daycare providers and may be attached to any school or camp provided form. It is not necessary (and is against our office policy) for us to separately fill in or sign blank forms provided by your school, camp or daycare.
All fields must be completed - only one request need be submitted for multiple siblings, list the names of all children needing school forms in the appropriate field below.
Name of person completing request: First Last Email address: Children's Medical Office Account #: This can be found on any office statement or receipt, or on any previous school form. Enter only digits to the left of, ignore digits after the decimal point (i.e. 1234.1, 1234.2, and 1234.3 together need only one form with # entered as 1234).
Name of person completing request: First Last Email address:
Name of person completing request: First Last
Email address:
Children's Medical Office Account #: This can be found on any office statement or receipt, or on any previous school form. Enter only digits to the left of, ignore digits after the decimal point (i.e. 1234.1, 1234.2, and 1234.3 together need only one form with # entered as 1234).
Name(s) of child(ren) for whom a school form is being requested: enter the first (and last if different from above) name of each child you need a form for.
Please Note: Requests are usually filled within 2 business days. School forms are mailed to the address we have on file for you at our office. We will provide one copy per child. You may xerox this yourself if additional copies are needed. Once mailed, a confirmation will be sent to the email address you provided above. Because parking is so limited at our office, picking up school forms in person is discouraged unless you have an appointment to come in anyway. To protect your child's privacy, we do not mail or fax these forms directly to third parties (such as schools, daycares, or camps). We recommend that you review the form carefully yourself prior to submitting it to such a third party, and contact us by telephone or email if you find either errors which need correcting or items you would prefer be kept confidential and therefore be deleted from the school form.
