BumoCare Physician's Report

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PHYSICIAN’S REPORT—CHILD CARE CENTERS
Is your child's session at a Licensed Family Home?*

YesNo, they are booked at a Licensed Center.
Physician Reports are required for Licensed Centers (not Licensed Family Homes). If you feel you might book a session for your child at a Licensed Center in the near future, you can save time by starting it now. Would you like to get that started? :)*

YesNo
You may close this window then. If your child is scheduled for a Licensed Center in the future, the Physician's Report will be required.

Have a great session!

(CHILD’S PRE-ADMISSION HEALTH EVALUATION)
PART A – PARENT’S CONSENT

(TO BE COMPLETED BY PARENT)
Name of Child*
Birth Date*
Name of Facility
Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to BumoWork Century City.
E-Signature of Parent/ Guardian or Child's authorized representative

Clear
Parent/ Guardian or Child's authorized representative*

First NameLast Name
Parent/ Guardian or Child's authorized representative Email*
example@example.com
(TODAY’S DATE)*

MonthDayYear
If you have a copy of your child's immunization records, please upload it here. Otherwise, you may email it to licensing@bumo.com

Cancelof
PART B – PHYSICIAN’S REPORT

(This section is for your physician to complete; at the end of this form, you will press SUBMIT and get a PDF emailed to you so that you can send the PDF form to your physician to complete the rest.)
Problems of which you should be aware:
Hearing
Allergies and medicine:
Vision
This is for your doctor to fill out.
Developmental
Food
Language/ Speech
Asthma
Dental
Other (Include behavioral concerns):
Comments/Explanations:
Medication Prescribed/Special Routines/Restrictions for This Child:
IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

Vaccine & Date Each Dose Was Given (MM/DD/YY):*

	1st	2nd	3rd	4th	5th
Polio (OPV or IPV)
DTP/DTaP/DT/Td
MMR
HIB Meningitis
Hepatitis B
Varicella (Chickenpox)

SCREENING OF TB RISK FACTORS (listing below):

Risk factors not present; TB skin test not required.Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented).Communicable TB disease not present.
RISK FACTORS FOR TB IN CHILDREN:

Have a family member or contacts with a history of confirmed or suspected TB.
Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).
Live in out-of-home placements.
Have, or are suspected to have, HIV infection.
Live with an adult with HIV seropositivity.
Live with an adult who has been incarcerated in the last five years.
Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in nursing homes.
Have abnormalities on chest X-ray suggestive of TB.
Have clinical evidence of TB.

* Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.
I __________ reviewed the above information with the parent/guardian.

HaveHave Not
Physician Name

First NameLast Name
Date of Physical Exam:

MonthDayYear
Date
Address
Date This Form is Completed:

MonthDayYear
Date
Telephone:
Please enter a valid phone number.
I acknowledge that I must send the PDF of the form to the child's physician to fill out "Part B". I understand that the report will not be considered "complete" until the form is filled out by the physician and returned via email to "licensing@bumo.com".
Signature:

Clear
Form completed and signed by:

PhysicianPhysician's AssistantNurse Practitioner
Should be Empty:

PHYSICIAN’S REPORT—CHILD CARE CENTERS

(CHILD’S PRE-ADMISSION HEALTH EVALUATION)

PART A – PARENT’S CONSENT

PART B – PHYSICIAN’S REPORT

I acknowledge that I must send the PDF of the form to the child's physician to fill out "Part B". I understand that the report will not be considered "complete" until the form is filled out by the physician and returned via email to "licensing@bumo.com".