Forms

A Child Health Form will be provided to you at annual well visit for patients age 4 years and up. This form includes the child’s medications, report of physical 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

• Physicians Report- Child Care Centers (for day cares and preschools)
• Report of Health Examination for School Entry (for Kindergarten and older)

School and Camp Forms

Please note: School forms change frequently. Several of these links go to a "forms" page or "athletics" page of your school website. Click on the appropriate link after accessing the site.

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

East Bay Pediatrics Forms

• Record Request Form Print, complete, sign and send this form to any other health care provider who may have medical records that would be helpful to your doctor at East Bay Pediatrics.
• Record Release Form Print, complete, sign and return this form to East Bay Pediatrics if you need your child's medical record. Please try to be as clear as possible regarding the reason you need the medical record and where to send it. Please note: medical records cannot be faxed!
• Flu Vaccine Form Please use this form when coming to East Bay Pediatrics for Drop-In Flu Vaccine (more information on Flu Vaccine page). Drop-in is available most days Monday through Friday 10am-noon and 2pm-4pm.

For New Patients

• Record Request Form Print, complete, sign and send this form to your child's previous doctor so that East Bay Pediatrics can have a complete record of your child's health information.
• New Patient Questionnaire Please complete this health questionnaire prior to your child's first visit to our office
• Consent Form One of these forms needs to be signed for each family in order for our physicians to care for your child in the event that someone other than yourself needs to bring your child to our office.
• Patient Information Form One of these forms should be completed for each child's chart