Town & Country Pediatric Forms
Click on the links below for a pdf version of our forms. You may fax them to your Town & Country Pediatrics office, or scan and email them to the following addresses contacts.
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New Patient Forms
Thank you for choosing Town & Country Pediatrics. We look forward to caring for your child. Listed below are the New Patient forms that we will ask you to fill out when you visit us in the office for the first time. If you like, you may download these forms in advance and bring them in with you to your first visit. All our forms are in a PDF format so you will need to have Adobe Acrobat installed in your browser to view the forms.
- Patient Registration Form - Registration information for new families joining our practice
- Consent to Examination and Treatment - This form authorizes a Lurie Children's Primary Care – Town & Country Pediatrics provider to examine and treat your child.
- Notice Privacy Practices Pamphlet - Detailed explanation of the policy.
- Notice of Privacy Practices Summary
- Plain Language Summary - This form describes the Ann & Robert H. Lurie Children's Hospital of Chicago Financial Assistance Program.
- Federal and State Mandatory Patient Notices
Listed below are forms that you may find helpful. If you like, you may download these forms in advance and fax them to the Town & Country Pediatrics offce that you will be visiting. All our forms are in a PDF format so you will need to have Adobe Acrobat installed in your browser to view the forms.
- Flu Consent Form 2016-2017 - Before bringing your child or children to their flu vaccine appointment, please print and fill out a flu consent form based on the location where your child will be vaccinated. Having the form ready at the appointment will save you time!
Halsted Flu Consent → Glenview Flu Consent → Lincoln Flu Consent →
- School Form - State of Illinois Certificate of Health Examination - This is the form commonly used by many schools, camps or day-care providers to document your child's health history. We provide an annual update of your child's health history as a courtesy to all families. Please remember to photocopy the completed form before turning it in to your school, camp or day-care provider. There is a nominal charge for the completion of more than one form per year. Please remember to give us at least ten business days notice if you need one of these forms for the school, camp or daycare center you are planning on attending. Thank you.
- Athletics - State of Illinois Pre-participation Examination Form - Check with your child's program to make sure that this is the preferred health form for participation in their athletic program. There is a nominal charge for the completion of more than one form per year. Please remember to give us at least seven days notice if you need one of these forms before they are allowed to participate in an athletic activity.
- Referral Request Form
- Vaccination Record Request - This form should be used to request vaccination records only. If more medical records are needed, please fill out the Authorization for Release of Patient Health Information form.
- Authorization for Release of Patient Health Information - This form needs to be filled out if you wish to have a copy of your child's medical records. Please note that it may take up to thirty days to obtain your child’s records for transfer.
- Minors Accompanied by Someone Other Than Legal Guardian - The purpose of this form is to identify individuals you would allow to bring your child for visits to Lurie Children's Primary Care – Town & Country Pediatrics and also to authorize the disclosure of information during visits.