Primary Care, Coatesville

Health Form Requests

Effective April 1, 2010

The following are guidelines when requesting a health form:

At your scheduled well child visit (check-up) if you have a form that needs to be completed, there will be no additional charge for the form that is done at the time of the well visit. Please remember to bring forms along at the time of your scheduled visit.
Your provider will print a health form (including immunizations) at the time of your well visit. This form can be copied and used throughout the year.
There is a $5.00 cash/check payment for all health forms to be completed regardless of the number of forms presented at one time (per child). If an additional form is needed later, another $5.00 fee will be charged. Your form will be completed in 2 – 3 business days upon receipt of payment for the form.
There is a $20.00 fee for a form that needs to be picked up on the same day. No rush requests will be accepted on a Saturday.
Please remember that a well child exam must have been documented within the last year in order for your form to be completed.

Main Number: 215-590-1000
Physician Referral Service: 1-800-879-2467
Coordinates: 39.9486937, -75.1929596
An Equal Opportunity Employer
The Children's Hospital of Philadelphia is an equal opportunity employer. We do not discriminate on the basis of race, color, gender, sexual orientation, age, religion, national or ethnic origin, disability or veteran status.