Forms

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.

Halsted Office:

Lincoln Office

Glenview Office

PDF’s require Adobe Acrobat Reader. Please click here if you do not have Reader.


New Patient Forms - Newborn Babies

Thank you for choosing Town & Country Pediatrics. We recommend seeing your baby within 3-6 days of his/her birth. Listed below are the Newborn 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
  • Family History Questionnaire - Documents your familes' medical and health history
  • Financial Policy - Explains the practice financial policies and our agreement with you
  • HIPAA - This notice describes how health information about you and your children (as patients of this practice) may be used and disclosed

New Patient Forms - Children

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
  • Family History Questionnaire - Documents your familes' medical and health history
  • Financial Policy - Explains the practice financial policies and our agreement with you
  • New Patient Record Form - Documents your child's health history. We need a separate form for each child.
  • HIPAA - This notice describes how health information about you and your children (as patients of this practice) may be used and disclosed

Other Forms

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 Vaccine Questionnaire 2012-2013 - Before bringing your child or children to their flu vaccine appointment, please print and fill out the attached form for each child. Having the form ready at the appointment will save you time!
  • 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 seven 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
  • Authorization for Treatment Form - This form authorizes individuals other than parents or guardians to bring your child to the office. We will need this form on file if you plan on having someone such as a non-parental family member, nanny or family friend bring your child to the office for medical care.
  • Medical Records Request - This form needs to be filled out if you wish to have a copy of your child's medical records.
  • Medical Records Request – Transferring From Another Practice to Town & Country - For use if your current pediatrics practice or specialized provider requires it for the copy and transfer of patient medical records.