Primary Care, Haverford

Health Form Requests

The following are guidelines when requesting a health form:

If you have already scheduled your well child visit (physical exam) and have a form that needs to be completed, there will be no additional charge for the form.
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 $10.00 cash payment for all health forms to be completed regardless of the number of forms presented at that one time. If an additional form is needed later, another $10.00 fee will be charged. Your form will be completed in 7 to 10 business days upon receipt of payment for the form.
There is a $25.00 fee for a form that needs to be picked up in 24 hours. If Pediatric & Adolescent Care, Haverford receives a rush on Friday or Saturday, it will be completed on Monday.
Please remember that a well child exam must have been documented within the last year in order for your form to be completed.
HIPAA laws require written authorization for completion of all health forms.
The Pennsylvania Interscholastic Athletic Association requires all athletes to have a physical exam after June 1 for completion of the PIAA sports clearance form for the following school year.

Call Haverford

600 Haverford Road
Suite 100

Haverford PA, 19041

610-658-1998

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.