Schedule Flu Vaccine or COVID Vaccine & Testing New Patient Access Patient Portal
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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.

    • Receive a call to pick upReceive a text to pick upMail (please provide mailing address)E-Mail (please provide email address)Fax* to School/Camp/Daycare Please do not select this option if you wish to review the formsprior to submission to school/camp/daycareFax* 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 :


    We are honored to participate in the care of your children. Watching your children grow is a wonderful and exciting experience. The changes happen so quickly, and it is a marvel that this tiny miracle you created gradually becomes a little person with a personality that is unique and special. We know how you feel. The doctors and staff at Potomac Pediatrics watch with pride as we see your children grow. Our team is committed to delivering comprehensive medical care that will address your family’s health and lifestyle needs. We strive to be accessible to our patients in times of need.
    We are honored to participate in the care of your children. Watching your children grow is a wonderful and exciting experience. The changes happen so quickly, and it is a marvel that this tiny miracle you created gradually becomes a little person with a personality that is unique and special. We know how you feel. The doctors and staff at Potomac Pediatrics watch with pride as we see your children grow. Our team is committed to delivering comprehensive medical care that will address your family’s health and lifestyle needs. We strive to be accessible to our patients in times of need.
    We are honored to participate in the care of your children. Watching your children grow is a wonderful and exciting experience. The changes happen so quickly, and it is a marvel that this tiny miracle you created gradually becomes a little person with a personality that is unique and special. We know how you feel. The doctors and staff at Potomac Pediatrics watch with pride as we see your children grow. Our team is committed to delivering comprehensive medical care that will address your family’s health and lifestyle needs. We strive to be accessible to our patients in times of need. Testing.

    Our Testimonials

    Maureen is AMAZING! I was able to get an appointment relatively quickly with her when my newborn was falling asleep in the middle of feedings. She spent upwards of an hour with me and shared many tactics and tips on how to get him to finish feedings. The newborn support group was awesome, as I

    Laurie E. 22 May, 2018

    We love Potomac Pediatrics and have recommended you guys to multiple friends! Friendly, clean, and prompt!- Hunter H.

    06 Jan, 2016

    Maureen is so knowledgeable, kind and helpful. She’s been consistently great at responding to my inquiries in a timely and thorough fashion. She’s just wonderful!

    Jana C. 22 May, 2018

    Maureen is so much more than an LC. “Other duties as assigned” are definitely part of her job – counselor, therapist, and overall baby guru just to name a few. She is so personable and friendly, but super knowledgeable as an RN and IBCLC, so she really can answer any of your questions (and she

    Kristin T. 22 May, 2018

    Maureen is amazing! If it wasn’t for her I would have stopped breast feeding both of my children much earlier than I wanted to. She cares so much about her patients and babies! The best resource for new mommies! She is fantastic!

    Holly W. 22 May, 2018

    • Our Latest Blog Articles

      • Here’s Why AviClear Is Trending for Best Acne Treatments in Bethesda, MD

        Thanks to AviClear, they won’t have to worry about it anymore. Here’s what you need to know about one of the best acne treatments in Bethesda, MD!Read more

      • Want a Permanent Hormonal Acne Treatment in Silver Spring? Choose THIS

        When your child’s hormones are raging, their skin often is as well. Blackheads, whiteheads, angry inflamed acne – none of it is fun for them. As a parent, it’s probably not much of a thrill for you either. When you visit an acne clinic, ask them about AviClear permanent hormonal acne treatment in Silver Spring.Read more

    • Learn more about our seminars and classes.

      • Join us for a FREE prenatal session. This session is led by one of our board certified pediatricians where they will share the vision of Potomac Pediatrics and help prepare you for welcoming your newborn into the world.
        Read more

    • Watch our videos.

      • Enjoy fun group or personalized health coach session with our pediatric Health Coach, Allison

      • Potomac Pediatrics is revolutionizing the patient experience with our one-stop shop approach.

      • Dr. Jeremy Fishelberg explains what a Physician Assistant is and the important role they play here at Potomac Pediatrics.

    • Accolades

      • Amy Kaplan, M.D.
        Voted as one of the “Top Doctors” in the Washingtonian Magazine for 2017. Dr. Kaplan is a board

        Read more

      • Caren Glassman, M.D
        Voted as one of the “Top Doctors” in the Washingtonian Magazine for 2017

        Read more

      • Dr. Jeremy Fishelberg explains what a Physician Assistant is and the important role they play here at Potomac Pediatrics.

        Read more

      • Cheryl Hari Sachs, M.D.
        Voted as one of “America’s Top Doctors” in Castle Connolly 2015. Dr. Sachs is a board certified

        Read more

      • Amy Kaplan, M.D.
        Voted as one of the “Top Doctors” in the Washingtonian Magazine for 2015. Dr. Kaplan is a board

        Read more

      • Caren Glassman, M.D
        Voted as one of the “Top Doctors” in the Washingtonian Magazine for 2015

        Read more

    Welcome to Potomac Pediatrics

    Welcome To Our Family

    We are honored to participate in the care of your children. Watching your children grow is a wonderful and exciting experience. The changes happen so quickly, and it is a marvel that this tiny miracle you created gradually becomes a little person with a personality that is unique and special. We know how you feel. The doctors and staff at Potomac Pediatrics watch with pride as we see your children grow. Our team is committed to delivering comprehensive medical care that will address your family’s health and lifestyle needs. We strive to be accessible to our patients in times of need.

    Philosophy

    Our goal is to offer you medical knowledge that is
    provided in a gentle manner and is easy to understand
    We pride ourselves in providing you evidence based medical care, and in that pursuit, we meet once a month to review the medical journals and current relevant studies. We maintain our board certification status by actively participating in continuing medical education.

    Why Choose Potomac Pediatrics?

    • Vaccinations

      Our practice offers walk-in flu vaccinations for the whole family!

    • Our Therapy Services

      Our practice offers expanded mental health services including individual and group therapy.

    • Healthy Habits Clinic

      Our Healthy Habits Clinic offers an interdisciplinary approach for both physical wellness and healthier lifestyle changes.

    © 2023 Potomac Pediatrics | All rights reserved | SITEMAP | Privacy Policy

    15204 Omega Drive Suite #100 Rockville, MD 20850

    Phone: 301-279-6750 | Fax: (301)-208-8953

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