Request School/Camp Form

 
  • School / Camp Form Request

    (for current patients only)

    Complete and submit this form, either on paper or online, 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.

    Name and email of parent/guardian completing form:

  • This can be found on any office statement or receipt, or on any previous school form. Enter only digits to the left of decimal (ignore the decimal point and digits after the decimal point i.e. 1234.1, 1234.2, and 1234.3 together need only one form with number entered as 1234).

  • One child per form, please.
  • Please Note: Requests are usually filled within 2 business days. School forms are EMAILED to the address we have on file for you at our office. We will provide one copy per child. You may copy this form yourself, or save it to your computer if additional copies are needed throughout the year. Once Emailed, 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 school, daycare, or camp). 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.

 

Fieldset

 

Verification