Patient Form Submission

Patient Form Submission
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Patient Form Submission
Turnaround time for forms is 5 business days (Mon-Fri). If you have multiple children, please fill out a separate form for each child.
Patient Information
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Email (to receive completed form):*

Confirmation Emailexample@example.com
Expedited
Requested Forms
Sports/School FormCamp FormIndividualized Health Plan (IHP)Medication AuthorizationImmunizations ONLYOther (such as FMLA, adoption, etc.)
If your child’s form requires ONLY their immunization history, this digital forms workflow is not for you. Instead, please fill out this Authorization to Release Immunization Records form so that we can send you a copy of your child’s Certificate of Immunization Status (CIS). CIS reports do not include a provider signature but are a verified record of their immunization history and are accepted by all schools and camps. If you are submitting a school sports form or a camp form that includes your child’s immunization history, you do not need to complete a separate Authorization to Release Immunization Records form.
Information required for the completion of Sports, School, Camp, and/or IHP forms:
YesNoUnsure
YesNoUnsure
Medical History
YesNo
YesNo
When?
Date
Where?
Country
YesNo
YesNo
Approximate date of hospitalization or major illness:*
Please describe hospitalization or major illness:*
COVID-19
YesNo
YesNo
YesNo
YesNo
Family Medical History
YesNo
Who was diagnosed?*
Age at diagnosis: *
Explain the new medical diagnosis: *
Other information:*
Add another family member and diagnosis
Who was diagnosed?*
Age at diagnosis: *
Explain the new medical diagnosis: *
Other information:*
Add another family member and diagnosis
Age at diagnosis: *
Who was diagnosed?*
Explain the new medical diagnosis: *
Other information:*
YesNo
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Information required for the completion of Medication Authorization forms:
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
YesNo
Preferred Pharmacy:*

Pharmacy Name

Street Address

CityState

Zip Code
An in clinic Well Child Check-up is required every 1-2 years in order for our providers to ensure your child is in physically fit to participate in activities. Please schedule an appointment with your child’s Primary Care Provider (PCP). Don’t forget to bring any forms to the appointment.

Schedule Appointment
Any extended paperwork (FMLA, adoption, etc.) requires a visit with one of our providers. Follow the link below to schedule an appointment. Virtual Visits work well for these types of appointments. Don't forget to bring any forms to your appointment.

Schedule Appointment
Please sign into your child’s Patient Portal account to view the date of their last Well Child Check-up. If you do not have a Patient Portal account, please click this link to register.

Patient Portal
YesNo
Upload Form(s)

A copy of all requested forms must be submitted. Failure to upload the necessary documents will cause a delay in processing.
Sports/School Form:*

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Camp Form:*

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Individualized Health Plan (IHP)*

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Medication Authorization:*

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Other Forms:

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Rush Processing

You will receive the completed form(s) securely via the email you provide within 5 business days, Monday - Friday (excluding holidays). If you need a form completed faster than our normal processing time, a rush fee of $20 per form will be charged for delivery within 1 business day, Monday - Friday (excluding holidays).
YesNo
Payment
Sports FormCamp FormIndividualized Health Plan (IHP)Medication Authorization
Calculation Total 1
Calculation Total 2
Payment Due:

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USD

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Patient Form Submission

Patient Form Submission

Patient Information

Requested Forms

Information required for the completion of Sports, School, Camp, and/or IHP forms:

Medical History

COVID-19

Family Medical History

Information required for the completion of Medication Authorization forms:

Upload Form(s)

Payment