Health Form Requests: Harborview/Smithville

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.

At The Children’s Hospital of Philadelphia and the CHOP Care Network, we are happy to help you get the medical records you need, when you need them.

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.

If you need a health form completed at a different time, a $10 fee will be charged for the first form; and $5 for each additional form. Please allow 7 business days after payment for these forms to be completed.

If you need a health form in a hurry, we will do our best to accommodate you. There is a $20 cash fee for a sports form that is needed the same day. The form must be received in the office by noon (weekdays only), in order for it to be completed by 3 p.m. that day.

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.

Downloadable forms




  • HIPAA English (PDF) — Authorization to release/obtain information 
  • HIPAA Spanish (PDF) — Authorization to release/obtain information (en Español)