Whether your child is entering daycare or school, or wants to participate in organized recreational activities, you may be asked to fill out a health form detailing your child’s medical history.
In most cases, your child must have been seen at a CHOP Care Network location for a complete check-up within the past 12 months for us to complete these forms. If this is not the case, you will need to schedule an office visit for your child.
Health forms are completed at the time of your child's physical exam. Please remember to bring the forms to your child’s visit. Your child’s provider will print a health form (including immunizations) at the time of your child’s well visit. This form can be copied and used throughout the year. Form fee charges will be $10.00 per form. Please allow 7 to 10 business days for completion
If you need a health form in a hurry, we will do our best to accommodate you. There is a $20 rush fee for a form that needs to be picked up within 24 hours. If we receive a rush form on Friday afternoon or Saturday, it will be completed on Monday.
There is no charge for completing medication dispensing forms or for copies of immunization records. These can be obtained by contacting the office directly and requesting a copy, and are also available through MyCHOP.
- HIPAA laws require written authorization for completion of all health forms.
- Universal Child Health Record (PDF) — used by most New Jersey daycare centers
- New Patient Registration Form (PDF)
- New Patient History Form (PDF)
- HIPAA English (PDF) — Authorization to release/obtain information
- HIPAA Spanish (PDF) — Authorization to release/obtain information (en Español)
- Modified Checklist for Autism in Toddlers (M-CHAT English) (PDF) — autism screening questionnaire for children 18-30 months old
- Modified Checklist for Autism in Toddlers (M-CHAT Spanish) (PDF) — autism screening questionnaire for children 18-30 months old (en Español)