Forms

A Child Health Form will be provided to you at every well visit for patients age 4 years and up. This form includes the child’s medications, exam, and immunization record. It can be used for school, camp, or sports participation. Please keep a copy for your records.

The State of California requires specific forms to be completed for both Day Care and School Entry. Certain schools or camps also have their own forms. Please bring these forms with you to your child’s well visit. There is a $10 charge for completion of forms not presented at the time of a visit for that child. Please allow a 7-10 day turnaround for forms brought separately from a child's visit.

State Forms

• California School Immunization Record
• Physicians Report- Child Care Centers
• Report of Health Examination for School Entry

School and Camp Forms

• Acalanes Union High School District Athletic Clearance
• Bishop O'Dowd High School Athletic Form Page 1
• Bishop O'Dowd High School Athletic Form Page 2
• De La Salle Athletic Form
• Piedmont High Athletics

East Bay Pediatrics Forms

• Seasonal Flu Vaccine Please use this form when coming to East Bay Pediatrics for Drop-In Seasonal Flu Vaccine (more information on Flu Vaccine page). Drop-in is available most days Monday through Friday 10am-noon and 2pm-4pm.
• H1N1 flu vaccine: This form is only available in the office and must be signed by a parent or guardian along with a time of service payment for the administration fee. (more information on the flu vaccine page)