Forms
Listed below you will find some commonly needed forms for school and daycare, as well as some charts and forms we use to keep track of medical information.
Feel free to download and print any of these forms. Please complete as much as you can yourself, before giving it to us.
We can return the completed form to you by fax. If you give us a self-addressed, stamped envelope, we can mail the completed form back to you (or to the school). Or you may pick it up when it's ready.
There is no charge for completing routine forms, if you bring the form with you at the time of the child's check-up. We must charge $10 for completing routine forms given to us during a sick visit, or between visits.
Form Description: | Download Form: |
|---|---|
| Rating scales are sometimes used to evaluate for ADHD. Here are scales developed by the AAP and Vanderbilt University. | ADHD Vanderbilt Scale - Parent Scale |
| Rating scales are sometimes used to evaluate for ADHD. Here are scales developed by the AAP and Vanderbilt University. | ADHD Vanderbilt Scale - Teacher Scale |
| Asthma "action plans" are sometimes required by school nurses, so that they have instructions when a child starts wheezing. These forms must be signed by the doctor. | Asthma Action Plan |
| Asthmatic children can benefit by keeping track of Peak Flow Meter readings over time. You may want to print this form, and show us the data you collect. | Asthma Flow Sheet - Peak Flow Meter Readings Chart |
| If you worry that your child doesn't eat enough, here's a sheet to count calories. | Calorie Count Spreadsheet |
| If your child attends a licensed day care in Delaware, you must fill out the top portion of this form and give it to us to complete. | Delaware Child Care Physical Form |
| Delaware schools must collect a doctor's form for each high school student involved in school sports. Please fill in as much information as possible (such as the child's name, address etc.) before bringing it to us for signing. (This form is updated for 2016 and after.) | Delaware Physical Form For High School Sports |
| This is the school physical form for entry into Delaware elementary schools. | Delaware School Physical K-8 |
| Form and guidelines for return to play, after COVID-19. | DIAA Covid-19 Return to Play_2020-2021 |
| Instructions to care for the ears, after we perform piercing. | Ear Piercing After Care |
| To give permission for us to perform ear piercing, print and sign this form. | Ear Piercing Release Form |
| It is useful for me to have a brief list of family illnesses. You can complete this form and bring it to your first visit. Check with all your close relatives! | Family History |
| If you decide to delay or decline routine vaccinations, we will ask you to sign this waiver. | Immunization Refusal Waiver |
| If your baby is jaundiced and we discussed drawing bloodwork, print this form. Fill in the name and birth date, and bring it to your lab. | Lab Order For Jaundice |
| Are you transferring your child's care to my office from another doctor? You may download this form, and send it to your previous doctor. (They may charge a fee for copying records.) | Medical Records Transfer Request |
| Please read our policy regarding our expectations of family financial obligations towards our office. | Patient Financial Policy |
| A skin test for Tuberculosis (PPD) is required for all new school entrants. The skin test must be checked 48-72 hours after we plant it. If the school RN is willing to check the reaction, please ask her to complete and fax this form to us. | PPD Fax-Back Form |
| New to our practice? Please download this package. You can read about our office, and get the forms that we will ask you to complete for us. | Welcome Packet |