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
RECORDS 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.
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.
| Records Request Form |
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.
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.
| Records Release 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
RECORDS REQUEST FORM (previous doctor)
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. Note: It may take your previous doctor 2-6 weeks to send us the appropriate information. Please request records as early as possible.
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. Note: It may take your previous doctor 2-6 weeks to send us the appropriate information. Please request records as early as possible.
| Records Request 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)
| New Patient 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 Form |
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 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 |
