Request For Medical Physical Form Completion printable pdf download

REQUEST FOR MEDICAL/PHYSICAL FORM COMPLETION

Patient Name:________________________________________

Date of Birth: _____________

Last Name,

First Name

Type of Form Needing Completion:

___ Day Care Form

(Please check one)

___ School Medication Form

___ Sports Physical Form

___ Kindergarten Assessment

___ Other (specify) _________

Please allow us approximately 5-7 business days for completion of form.

Date Form Dropped off: ___________

Date Form Needed for Pick Up: ____________

Please list a daytime phone number where you may be reached to inform you when form is

completed and ready for pick up :

(_______)________________

(area code)

Phone Number

______________________________________

_______________________________

Name of Person To Pick up Form

Relationship to Patient

If person picking up form is other than patient/parent, please specify full name and relationship.

Please be advised that due to our policies regarding the Privacy of Patient Health Information,

our staff will ask for a photo ID of person picking up form.

If unable to pick up, would you like us to mail to your home address?

YES____

NO____

Please provide us with a stamped self-addressed envelope.

Please verify your home mailing address:

____________________________

Street no. (P.O. Box)

____________________________

City,

State

Zip

Due to the need for maintaining the privacy of our patient’s medical information, we prefer that

the form either be picked up or mailed to your home address. We do understand that

extenuating circumstances may occur that would require us to fax the completed form to you.

You may request our office to fax the completed form. Please complete below:

_______________________________

_____________________________

Person/Company To Whom to Fax

Secured Fax Number

I give my permission to Jeffers, Mann and Artman Pediatric and Adolescent Medicine,

P.A./Clayton Pediatric and Adolescent Medicine to fax the requested form to the person and

number specified above. I also give authorization for Jeffers, Mann and Artman Pediatric and

Adolescent Medicine, P.A./Clayton Pediatric and Adolescent Medicine to release completed form

to the above named person in the event the patient, parent or legal guardian is unable to pick

up.

______________________________________

_______________________

Signature of Patient, Parent, or Legal Guardian

Relationship to Patient

Request For Medical Physical Form Completion

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