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
If yes, please list all medications and dosages. Including any over the counter, herbal,vitamins, or sports supplements.
Will these medications be taken at school/ camp/ daycare? YesNo
If yes, are there specific times the medication needs to be given? Dosages?
Does your child have any allergies to food or medications? YesNo
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.
YesReceive a call to pick up
YesReceive a text to pick up
YesMail (please provide mailing address):
YesE-Mail (please provide email address):
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
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 :
15204 Omega Drive Suite #100 Rockville, MD 20850
Phone: 301-279-6750 | Fax: (301)-208-8953
Website Design by COGO Interactive