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301-279-6750

Phone

15204 Omega Drive

Suite #100 Rockville, MD 20850

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Health Form Submission

**Questions? Please submit any questions or status requests to HealthForms@PotomacPediatrics.com**

School/Camp/Daycare
Forms Request

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 if required on the form.  If you ONLY need an immunization record, follow the instructions in the navy blue box below.

  • 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.  We do NOT accept expedited requests. If you need forms same day, please schedule an appointment in our office or at POP NOW to have your clearance forms completed. Please note, appointments for sports physicals are subject to a $50 self pay fee due at the time of service.
  • If multiple siblings 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.

Step 1: Find and Complete the appropriate form from the list below

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

  • If your child is entering an MCPS school for the first time or is entering Kindergarten, you will need to complete the MCPS Student Record Card.
  • This form includes the COVID-19 supplemental questions sheet.
  • On the cover sheet please specifically list the medication you are requesting this for this form.
  • 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.
School/Camp Form not listed? Click here to upload your form

Step 2: Check your email

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 or GoDaddy.  Emails occasionally end up in a junk/spam folder, be sure to check here. The encrypted link will expire after 48 hours so please open immediatley! 

Please allow 5-7 business days to receive your form.

Immunization Records ONLY

If you ONLY need Immunization records, click the button below

Immunization records are included with each School/Camp form where immunizations are required, 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

Immunization Record Request

Need Help?

Click here for hour helpful, step-by-step “how to guide” or submit your question using the form below

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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