Forms and Policies
Medical Record Forms (Medical records may take up to 4 weeks to process)
Organization and school forms (Allow 7-10 business days for form processing)
HIPAA forms and policies
Notice Of Privacy HIPAA Consent Form Medical/Financial Information Medical/Financial
Practices Disclosure Policy Info. Disclosure Form
General forms and policies
Financial Policy Over the Counter Over the Counter Split Vaccine Charge
Medication Policy Medication Request Form
Release & Consent Consent to Treat
Vaccine Information Sheets (VIS) Click on the vaccine name
Prescription refill request
If there are not any changes to your prescription refill please email the following information: Patient Name, Patient Date Of Birth, Pediatricianís name, Parentís Name, Parentís Phone Number, Pharmacy name and phone number, Medication Name, and Medication strength and dosage. (If there are any changes or this is a new request please call our office during normal business hours)
firstname.lastname@example.org to email a Prescription refill request
Immunization/Medical record request
For a medical record or immunization request please email the following information:
Patient Name, Patient Date of Birth, Call Back Number, a Reason of your request, and where you would like us to send the information.
email@example.com to email a medical record or immunization request
You can also call our office during normal business hours or leave a message after hours for any of these requests.
When you send an email transmission, the email is not necessarily secure and is not encrypted. Email transmissions are not necessarily protected from unauthorized access. Sending email is at your own risk. We cannot accept responsibility for your transmission of confidential information or any obligation with respect to that information not submitted over a secure server.