Medical Records & Other Forms

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.

Medical Records Request 

You can reach medical records at 312.279.8913 or TCPrecords@luriechildrens.org

Download a medical records request form

Vaccination Records Request Form 

This form should be used to request vaccination records only.

Download a vaccination records request form

Patient Forms

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. 

Other Forms

Listed below are forms that you may find helpful for your child’s school, camp or daycare. You may download and submit these forms at the time of a visit or you may fax or scan/email them to the Lurie Children's Primary Care – Town & Country Pediatrics office of your choice. 

Halsted Office

Lincoln Office

Glenview Office