Form Cover-sheet

Patient Name:DOB:Today's Date:

Please Provide a Contact Number: Email:

please list the facility name and type of form (ex: BAR-T Camp Form, JDS School, etc.):

• Have you completed your portion of the forms? Yes

• Please ask if you’re unsure about what section you need to complete.

• Is your child currently taking any medications?    YesNo

1. If yes, please list all medications and dosages. Including any over the counter, herbal,vitamins, or sports supplements.

2. Will these medications be taken at school/ camp/ daycare? YesNo

3. If yes, are there specific times the medication needs to be given? Dosages?

• Does your child have any allergies to food or medications?  YesNo

1. If yes, please list below.

• Is there anything else that you would like the school/ camp or daycare to know about your child? YesNo

• Does your child wear eyeglasses or contact lenses?  YesNo

• Does your child wear braces?  YesNo

HOW WOULD YOU LIKE TO RECEIVE THE FORMS BACK?

Please select one option from below.

1. YesReceive a call to pick up

2. YesReceive a text to pick up

3. YesMail (please provide mailing address):

4. YesE-Mail (please provide email address):

5. YesFax* to School/Camp/Daycare Please do not select this option if you wish to review the forms
   prior to submission to school/camp/daycare

6. YesFax* to Home/Work*Please Provide Fax Number:

*I authorize Potomac Pediatrics to fax my child’s forms to the provided fax number above. Initial:

OFFICE USE ONLY RECEIVED BY: NCSF PAID?

Attach Form :