Here are some common forms that you may find helpful.
Please complete the parent portion of the form prior to bringing to the office. If dropping off a form, please allow 5 business days for completion.
Forms will be completed free of charge at your child’s well visit. There is a $5 fee for any form that needs to be completed outside of the well child visit. Payment for the form must be made when the form completion is requested. A $10 fee will be charged for a form that needs to be completed on the same day as the request is made.
For us to complete any form, your child’s well visit must have been within the time frame recommended for their age (within the last 12 months for school-aged children, or shorter intervals for younger children.)
- Demographic Information (Please download, complete, and bring to the office for your visit)
- Patient Portal Registration Form (Please download, complete, and bring or fax to the office)
- Consent for children 16 years and older to come alone for sick visits
- Records Release of information to East Suburban Pediatrics from another provider
- Records Release of information from East Suburban Pediatrics to another provider