Health forms are a necessary process when it comes to enrolling your child in school, sports, camp, or other physical activities. We are striving to make your lives easier when it comes to these forms. With our updated process you can expect the following:

  • Easier completion & submission
  • Faster turnaround time
  • HIPAA complaint & secure
  • Increased reliability from start to finish

All you have to do is follow these easy steps: 

  1. Pick the correct health form below that pertains to your child
  2. Electronically complete the parent section of the form
    • Required fields must completed in order to submit your forms
  3. Digitally sign your form and hit submit.
  4. Check your email and verify your digital signature. 

After you’ve submitted your forms (via verifying your digital signature) they will immediately drop into our queue for  completion. When your forms are completed, you will immediately receive a finalized copy in your email.

Bullis Health Forms

Bullis School Physical Examination Form

Bullis School Asthma Action Plan & Authorization

Bullis School Allergy Action Plan

Camp Forms

Capital Camps

Camp Airy/ Camp Louise – Please complete this form in PDF format, save to your desktop, and attach to the cover sheet below.

Boy Scouts Camp

JDS Health Forms

JDS Physical

JDS Sports Physical Examination

JDS Authorization to Administer Prescribed Medication

JDS Non-Prescription Medication Authorization

JDS Anaphylaxis/ Severe Allergy Action Plan

JDS Asthma Action Plan (The ALA Asthma Action Plan form is the preferred form for JDS)

Maryland State Forms

Maryland State Health Inventory Form

MD State Health Inventory Childcare Form

Maryland State Childcare Medication Authorization Form

Maryland State Asthma Medication Authorization Form

Montgomery County Health Forms

MCPS Health Inventory Forms

  • If your child is entering a MCPS school for the first time or is entering Kindergarten, you will need to complete the MCPS Health Inventory Form.

MCPS Pre-Participation Form for Athletes

MCPS Authorization to Administer Prescribed Medications

  • If your child will need prescription medication or over-the-counter medication at school, you must complete one form for each medication. Please note this is a mandatory requirement per MCPS.

MCPS Epipen Authorization

Miscellaneous Health Forms

Georgetown Prep Health History Record 2017 School Year

Green Acres OTC Medication Form

Boy Scouts Scouting Events Participation

Montgomery Sports Association (MSA) Medication Authorization Form

American Lung Association Asthma Action Plan

 

Is your school/camp form not available?

Email question@potomacpediatrics.com a blank PDF copy and we’ll build an online version within 48 hours for future automatic submission.

Health forms not available on our website through automatic submission may be submitted by completing the cover sheet below and attaching your forms. Please ensure the parent section is completed prior to submitting your forms. Failure to complete the cover sheet and/or parent section will result in your forms being rejected.

Please note that all forms may take up to 7 business days to be completed. We receive the highest volume of health forms April-August, resulting in completion times that may take the full 7 days. Forms are completed as they are submitted. There is no fast-track or expedited process for late submissions. 

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

  • Does your child have any allergies to food or medications? 
    1. If yes, please list below.

  • Is there anything else that you would like the school/ camp or daycare to know about your child? 
  • Does your child wear eyeglasses or contact lenses?  
  • Does your child wear braces?  

HOW WOULD YOU LIKE TO RECEIVE THE FORMS BACK?

Please select one option from below.

  1. Receive a call to pick up
  2. Receive a text to pick up
  3. Mail (please provide mailing address):
  4. E-Mail (please provide email address):
  5. Fax* 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. Fax* 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 :