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.
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 – Town & Country Pediatrics and also to authorize the disclosure of information during visits.
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.
School and Athletic Form – State of IL – Use this to request a State of Illinois Certificate of Health Examination form or IHSA Pre-Participation Physical Examination Form. Check with your child’s school or program to make sure that this is the preferred health form. All other program specific forms should be provided by you.