Submitting Health Forms:

Please note: Common health forms are available below for your convenience

  1. Complete the parents/guardians section of your child’s health form
    • This section must be completed when submitting health forms
  2. Please put your child’s name on the top each page where applicable
  3. Complete the cover sheet below
  4. Attach your completed forms in pdf format and click submit
  5. Please allow 5-7 business days for the completion of your forms.

*Please note: An updated immunization record will be attached with all forms submitted.

*If submitting a MCPS Pre-participation sports clearance form please note that only page 4 is required to be completed.  Click here for pre-participation form instructions.

 

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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 :


 

Health Inventory Form

Click on the form you need

  1. Complete the parents/guardian section digitally
  2. Save this form to your desktop in pdf format
  3. It should automatically try to save as a pdf file
  4. You are now ready to complete the web based cover sheet and submit your forms.

HIPAA Compliant Secure Email Registration Instructions

 

Montgomery County Health Forms

MCPS Health Inventory Forms

MCPS Pre-Participation Form for Athletes

MCPS Authorization to Administer Prescribed Medications

MCPS Epipen Authorization

MD State Health Inventory Childcare Form

 

Frequently Submitted Camp Forms

Capital Camps

Camp Airy/ Camp Louise

Boy Scouts Camp

Boy Scouts Scouting Events Participation