Medical Records & Other Forms for Town & Country Pediatrics Patients

Make an Appointment 

Halsted: 312.227.2800 | Skokie: 312.227.2860 | Glenview: 312.227.2850

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. Forms can also be requested on MyChart.

Medical Records Request 

You can reach medical records at 312.227.2806 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. 

• 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 – Town & Country Pediatrics and also to authorize the disclosure of information during visits.
• What's Important Today? (Optional)

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. 

• 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.
• Referral Request Form

Halsted Office

• Fax: 312.227.9551
• Halsted Office Email

Skokie Office

• Fax: 312.227.9557
• Skokie Office Email

Glenview Office

• Fax: 312.227.9555
• Glenview Office Email