East Bay Pediatrics
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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.
Records Request Form
File Size: 56 kb
File Type: pdf
Download File


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.
Records Release Form
File Size: 64 kb
File Type: pdf
Download File


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.
Patient Portal Form
File Size: 67 kb
File Type: pdf
Download File


CONSENT FORM
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)
File Size: 129 kb
File Type: pdf
Download File


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.
Records Request Form
File Size: 56 kb
File Type: pdf
Download File


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)
New Patient Questionnaire
File Size: 72 kb
File Type: pdf
Download File


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.
Consent Form
File Size: 146 kb
File Type: pdf
Download File


PATIENT INFORMATION FORM
One of these forms should be completed for each child's chart.
Patient Information Form
File Size: 73 kb
File Type: pdf
Download File


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.
Patient Portal Form
File Size: 67 kb
File Type: pdf
Download File

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  • Home
  • New Patients
    • Expecting Parents
    • Transferring Patients
  • Appointments
    • Schedule an Appointment
    • Routine Well Visit Schedule
    • Vaccinations
    • Flu Vaccine
    • COVID-19 Vaccine
    • COVID-19 Vaccine 2023-24
    • RSV injection 2023-24
  • Contact us
    • Location & Hours
    • Email & Phone
  • Health Resources
    • Health Topics
    • Health Blog
    • Medications
  • About EBP
    • Our Practice
    • Meet Our Providers
    • Meet Our Staff
    • Our Specialties >
      • ADHD Management
      • Mental Health
      • Eating Disorders
      • Gender-Affirming Medicine
      • Newborn Care
    • Office Policies
    • FAQs
  • Forms & Quick Access
    • Forms
    • Schedule an Appointment
    • Routine Well Visit Schedule
    • COVID-19 Vaccine Sign Up
    • Flu Vaccine Sign Up
    • Berkeley Urgent Care Sign Up
    • Orinda Urgent Care Signup
    • Patient Portal Login
    • Online Bill Pay