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 addressesof your Town & Country Pediatrics office, at the bottom of this page.
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 Form - State of Illinois Certificate of Health Examination – Use this to request a State of Illinois health form. The State of Illinois requires a DCFS health form to be completed by a physician for all students entering preschool, kindergarten, sixth and ninth grade, a college freshman OR entering any State of Illinois school for the first time at any grade level.