Forms & Records
Click on the links below for PDF versions of our forms. You may fill them out and fax or scan/email them to the fax numbers or email addresses of your Town & Country Pediatrics office, at the bottom of this page.
New Patient Forms
We look forward to caring for your child. Listed below are the New Patient forms that we will ask you to fill out when you visit us in the office for the first time. If you like, you may download these forms in advance and bring them in with you to your first visit.
Listed below are forms that you may find helpful including forms for your child’s school, camp or daycare. If you like, you may download these forms in advance and fax or scan/email them to the Lurie Children's Primary Care – Town & Country Pediatrics office that you will be visiting.
- Flu Consent Form – Before bringing your child or children to a walk-in flu clinic, please print and fill out a flu consent form. Having the form ready will save you time!
- School Form - State of Illinois Certificate of Health Examination – This is the form commonly used by many schools, camps or day-care providers to document your child's health history. The State of Illinois requires a DCFS health form to be completed by a physician for all students entering preschool and kindergarten, students entering any State of Illinois school for the first time at any grade level, students entering the sixth and ninth grade and for college freshman. We provide an annual update of your child's health history as a courtesy to all families. Please remember to photocopy the completed form before turning it in to your school, camp or day-care provider. There is a nominal charge for the completion of more than one form per year. Please remember to give us at least 10 business days' notice if you need one of these forms for the school, camp or daycare center you are planning on attending. Thank you.
- Athletics – State of Illinois Pre-participation Examination Form – Check with your child's program to make sure that this is the preferred health form for participation in their athletic program. There is a nominal charge for the completion of more than one form per year. Please remember to give us at least 10 business days' notice if you need one of these forms before they are allowed to participate in an athletic activity.
- Referral Request Form
- Vaccination Record Request – This form should be used to request vaccination records only. If more medical records are needed, please fill out the Authorization for Release of Patient Health Information form.
- Authorization for Release of Patient Health Information – This form needs to be filled out if you wish to have a copy of your child's medical records. Please note that it may take up to 30 days to obtain your child’s records for transfer.