Forms & Records for Chicago Area Pediatrics Patients
Click on the links below for PDF versions of our forms. You may fill them out and fax or scan/email them to 312.227.9680 or email@example.com
Forms can also be requested on MyChart.
Medical Records Request
You can reach medical records at 312.227.1160 or firstname.lastname@example.org
Download a medical records request form
Vaccination Records Request Form
This form should be used to request vaccination records only.
We look forward to caring for your child. Listed below are the forms that we will ask you to fill out when you visit us in the office for the first time, some of them are updated yearly. You may download and complete these forms at your convenience to save time during your visit.
- Consent for Care and Services
- Federal and State Mandatory Patient Notices
- Plain Language Summary
- Notice of Privacy Practices Summary
- Patient Registration Form
- Notice Privacy Practices Pamphlet
- Minors Accompanied by Someone Other Than Legal Guardian – The purpose of this form is to identify individuals you would allow to bring your child for visits to Lurie Children's Primary Care - Chicago Area Pediatrics and also to authorize the disclosure of information during visits.
If you need a form completed for school, athletics, camp or for another reason, please call or email the office during business hours at 312.227.1160 or email@example.com for assistance