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Phone
Suite #100 Rockville, MD 20850
Please follow the steps below to request your School/Camp/Daycare form. A copy of your child’s immunization record will be included with this form.
Your child must have a Well Child Exam (WCE) within the past 12-months in order for a form to be completed. Forms submitted without a WCE in the past 12-months will be declined or held until a WCE appointment is completed.
Please allow 5-7 business days for forms to be returned to you.
If multiple forms are submitted, they may be returned at different times or different days.
Forms must be submitted through this process, we do not accept paper forms in the office.
If you ONLY need Immunization records, click the button below
Immunization records are included with each School/Camp form, you DO NOT need to submit a separate request.
Please note records are not individually signed, the Potomac Pediatrics stamp on the form serves as the signature
If your form is not included in this list, please click the button at the bottom of this section
Once you complete the form and verify your digital signature the form will be dropped into our queue
Once a form is complete, it will be dropped into the queue. Forms will be completed in the order they were received
Completed forms will be sent to you via encrypted email from ProofPoint. Emails occasionally end up in a junk/spam folder, be sure to check here.
Please allow 5-7 business days to receive your form.
Potomac Pediatrics will always be fully focused on helping your child and you to overcome any healthcare hurdle, with innovative, comprehensive and compassionate care.
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