Vaccine Appt - Book Now New Patient Access Patient Portal
logo

test form

    logo

    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

    As a new mom I looked forward to getting together twice a month with these moms, get feedback and advice from Maureen, and just have some extra support in those first few months! I got lucky that the issues I had with breastfeeding were minor compared to some of the other moms, but it was

    Shirin M. 22 May, 2018

    Amazing. Love the style of the office. The technology, the humor, and the staff all come together for an awesome experience. Chris A.- Gaithersburg, MD

    14 Jan, 2016

    Absolute professionalism. Entire Staff was attentive and friendly.- Nicole C.

    06 Jan, 2016

    I met with Maureen a few days after being discharged from the hospital with my first born. Maureen was supportive, encouraging, and nonjudgmental. She answered all of my questions and encouraged me to reach out to her if I had any questions after our appointment. I very highly recommend her!

    Lauren B. 22 May, 2018

    Maureen was an incredible support during my first few weeks with a baby. For numerous reasons, breastfeeding never ended up being possible for me, but while we were trying hard to make it work, Maureen was my main source of knowledge and support. I think it would have been a lot more emotionally devastating to

    Jenna D. 22 May, 2018

    • Our Latest Blog Articles

      • What is Parvo B19 & Why is it in the News?

        By Leslie Gallon, NP   Parvovirus B19 Awareness: Signs, Symptoms, and Supportive Care School is back in session and with that comes new friends, new experiences, and unfortunately exposure to new germs. If you’ve been watching the new recently you know there has been a lot of buzz about a virus called Parvovirus B19.. KeepingRead more

      • Back-to-school season is in full swing, and for young athletes, that means one thing: It’s time for sports physical appointments in Montgomery County!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.

    © 2024 Potomac Pediatrics | All rights reserved | SITEMAP | Privacy Policy

    15204 Omega Drive Suite #100 Rockville, MD 20850

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

    Website Design by COGO Interactive