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.
If you need a health form completed at a different time, a $10 fee will be charged for all forms completed, regardless of the number submitted (per child). Please allow seven 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 rush fee for a form that needs to be picked up within 48 hours. No rush requests will be accepted on Saturdays.
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.
Driver’s Permit Physical Examination forms will be completed free of charge, but the patient must be present to sign the form in front of the physician. Please call the office in advance for a time that is mutually convenient for this meeting. Note: Pennsylvania driver's permit forms require that the physical exam be done within 6 months of your child turning 16 and the examination form is good for one year.
- 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.
- Child Health Report (PDF) — used by most Pennsylvania daycare centers
- Universal Child Health Record (PDF) — used by most New Jersey daycare centers
- PIAA Comprehensive Initial Pre-Participation Physical Evaluation (PDF)
- NJ Department of Education Annual Athletic Pre-Participation Physical Examination Form (PDF)
- Pop Warner Little Scholars Physical Form (PDF)
- New Patient Registration and History Form (PDF)
- Current Patient Health History Update (PDF)
- Change of Address or Insurance Form (PDF)
- PA Driver’s Permit Physical Examination Form (PDF)
- HIPAA English (PDF) — Authorization to release/obtain information
- HIPAA Spanish (PDF) — Authorization to release/obtain information (en Español)
- Authorization to Discuss Patient Medical Care (PDF) — for children 18 and older who wish to share medical records with parents or guardians
- Medical Authorization/Permission to Treat Form (PDF)