Patient Form Submission Payment

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
Date

MonthDayYear
Date
Expedited
Requested Forms
Select all that are needed:*

Sports FormCamp FormCertificate of Immunization (CIS) ReportIndividualized Health Plan (IHP)Medication AuthorizationSchool Admissions Form
CIS reports are available for free through MyIR Mobile. In partnership with the Washington State Department of Health, MyIR Mobile provides secure, anytime access to your child’s immunization records. To view and print a CIS report, visit the MyIR Mobile website to create an account and link your child’s information. For support, call (866) 397-0337 or email MyIR@doh.wa.gov.

If you’re submitting a school, sports, or camp form that already includes your child’s immunization history, you do not need to complete a separate CIS request.
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
Information required for the completion of Sports, School, Camp, and/or IHP forms:
Have you had a wellness check-up in the last year (or 2 years if your form allows)?*

YesNoUnsure
Camp Start Date:

MonthDayYear
Date
Camp End Date:

MonthDayYear
Date
Active Medications:*
Medical History
Does your form require TB screening?*

YesNo
Has your child ever travelled outside the U.S. for more than 6 concurrent months?*

YesNo
When?*
Date
Where?*
Country
Has your child ever been directly exposed to someone with tuberculosis (TB) disease or a positive TB screening test?*

YesNo
Has your child been hospitalized or had a major injury or illness since their last wellness visit?*

YesNo
Approximate date of hospitalization or major illness:*
Please describe hospitalization or major illness:*
COVID-19
Has your child ever had confirmed or suspected COVID-19 infection?*

YesNo
Did your child have 4 or more days of fever (>=100.4) and/or 4+ days of significant muscle aches/fatigue?”*

YesNo
Was your child hospitalized?*

YesNo
Is your child still experiencing any chest pain, shortness of breath, dizziness with exercise, new heart palpitations, or new fainting?*

YesNo
Family Medical History
Have there been any significant new medical diagnoses in your family 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:*
Are there any medications, including over the counter (OTC) products, your child will need authorization to take while at camp?*

YesNo
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Information required for the completion of Medication Authorization forms:
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Add another medication
Name of prescription or over the counter (OTC) medication:*
Dose:*
If you are requesting authorization for an asthma or allergy medication that was prescribed by an Allegro doctor, do you need a refill?*

YesNo
Please select the prescribed medication you need a refill for:*

Asthma Rescue Inhaler (Such as Albuterol or Xopenex)Asthma Controller (Such as Flovent, Symbicort or QVAR)Epinephrine Auto-Injector/Nasal Spray (Such as Epi-Pen or Auvi-Q)
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
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
Upload Form(s)

A copy of all requested forms must be submitted. Failure to upload the necessary documents will cause a delay in processing.
I already submitted my child’s school, sports, camp, medication, and/or IHP form(s) at one of the Allegro clinic locations.

YesNo
Sports Form:*

Only PDF files will be accepted. Please make sure PDFs are not password protected. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
School Form:*

Only PDF files will be accepted. Please make sure PDFs are not password protected. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Camp Form:*

Only PDF files will be accepted. Please make sure PDFs are not password protected. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Individualized Health Plan (IHP)*

Only PDF files will be accepted. Please make sure PDFs are not password protected. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
Medication Authorization:*

Only PDF files will be accepted. Please make sure PDFs are not password protected. We recommend using a laptop or desktop computer to upload all forms.
Cancelof
I verify that only one form has been submitted per upload box. I understand that submitting multiple forms as a single upload will result in an additional charge and a delay in processing.*

I agree
Information required for the completion of Certificate of Immunization (CIS) Report
Who is requesting this release?*
Reason for Request?*
Which school grade/year are these records being requested for?*
Parent/Guardian Name*

First NameLast Name
Name of Organization*
Relationship to Patient*
Contact Number *
Please enter a valid phone number.Format: (000) 000-0000.
Record to be released to:*
Due to security, this option is limited to postal mail, which can take up to two weeks. To expedite, we recommend having the record sent to the patient or parent/guardian via email and forwarding it to the third party.
Release method:*
Postal mail can take up to two weeks for delivery. To expedite, we recommend having the record sent via secure email.
*
Person/Organization
*
Contact Number
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email*

Confirmation Emailexample@example.com
Parent/Guardian Email*

Confirmation Emailexample@example.com
Signature
Warning - This Patient is over 18 and must submit this request.

By law, release of this record must be authorized by the patient.
Age
Today's Date

MonthDayYear
Date
I verify that I have completed all patient/parent sections of the form(s) being submitted to Allegro Pediatrics. I accept the liability for any incomplete and/or incorrect information submitted.*

I agree
Payment
You have selected 1 form for a cost of $20
You have selected 2 forms for a cost of $35
You have selected 3 forms for a cost of $50
You have selected 4 forms for a cost of $50
You have selected 5 forms for a cost of $50
You have selected 6 forms for a cost of $50
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 your form(s) completed faster than our normal processing time, a rush fee of $30 will be charged for delivery within 2 business days, Monday - Friday (excluding holidays)
Would you like your forms expedited for an additional $30 cost?

YesNo
Date

MonthDayYear
Date
File Name:
File Name 2:
(Exp) 30
Calculation Total 2 (Exp)
Calculation Total 1
Calculation Total 2
Final Payment Total

Should be Empty:

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)

Information required for the completion of Certificate of Immunization (CIS) Report

Warning - This Patient is over 18 and must submit this request.

Payment

Credit Card