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. Please note that Urgent Forms (requested turnaround in 48 business hours or less) will now incur a fee of $25. Routine forms will still have the basic fee of $10.
EAST BAY PEDIATRICS FORMS
RELEASE OF PATIENT INFORMATION
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. Note: It may take your previous doctor 2-6 weeks to send us the appropriate information. Please request records as early as possible.
Complete this form if you would like East Bay Pediatrics to release medical information to another provider or if you'd like to request a copy of your child's medical records.
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. Note: It may take your previous doctor 2-6 weeks to send us the appropriate information. Please request records as early as possible.
Complete this form if you would like East Bay Pediatrics to release medical information to another provider or if you'd like to request a copy of your child's medical records.
| release of information form |
PATIENT PORTAL FORM
Complete this form for access to your child's medical record online or on your smartphone. This form is also required for login access to email your doctor.
Complete this form for access to your child's medical record online or on your smartphone. This form is also required for login access to email your doctor.
| Patient Portal Form |
CONSENT FORM
This form allows us to speak with a parent or guardian of our patients who are 18 years old and over.
This form allows us to speak with a parent or guardian of our patients who are 18 years old and over.
| Consent Form (18 years old and over) |
FOR NEW PATIENTS
NEW PATIENT/PARENT INTAKE FORM
New families transferring from another practice please start by completing the new patient intake form. Parents expecting a baby please complete the new parent intake form. Once our coordinators receive the form and create your account they will call you to schedule your appointments and/or prenatal meet & greet.
New families transferring from another practice please start by completing the new patient intake form. Parents expecting a baby please complete the new parent intake form. Once our coordinators receive the form and create your account they will call you to schedule your appointments and/or prenatal meet & greet.
| new patient intake form |
| new parent intake form |
NEW PATIENT QUESTIONNAIRE
Please complete this health questionnaire prior to your child's first visit to our office (Note: please complete this form only if your child is over 2 years of age)
Please complete this health questionnaire prior to your child's first visit to our office (Note: please complete this form only if your child is over 2 years of age)
| np health questionnaire |
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 (e.g. your nanny or your parent) needs to bring your child to our office.
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 (e.g. your nanny or your parent) needs to bring your child to our office.
| consent to treat a minor 0-11 |
PATIENT INFORMATION FORM
One of these forms should be completed for each child's chart.
One of these forms should be completed for each child's chart.
| patient registration form |
PATIENT PORTAL FORM
Complete this form for access to your child's medical record online or on your smartphone. This form is also required for login access to email your doctor.
Complete this form for access to your child's medical record online or on your smartphone. This form is also required for login access to email your doctor.
| Patient Portal Form |
