We are happy to provide our office forms that may be filled out Online and securely emailed to our office (HIPPA secure), or may be downloaded on your home computer. Please either fill out the forms online and submit them to us, or print and complete the forms below and bring them with you to your child's first appointment. Questions about which forms you need? Please call our office and our courteous staff will assist you in preparing for your child's first visit.
General Intake Packet
I-Care (Illinois Comprehensive Automated Immunization Registry Exchange) is a web based immunization record-sharing
application developed by the Illinois Department of Public Health (IDPH). The application allows public and private healthcare
providers to share the immunization records of Illinois residents with other physicians statewide.
- Please fill in the information online and print it out and fax it to (815) 609-8111 or mail it to our office address listed above
Medical Release Forms
- This is a form to release medical records TO Kids First Pediatrics
- This must be printed out and sent to you child's previous provider(s)
- Please fill in the information and forward it to your former medical provider(s).
- Please note that it may take a few weeks from the time that your former medical provider receives the request until we receive the records.
- Your former medical provider may charge a fee for photocopying the records
- This is a form to release medical records FROM Kids First Pediatrics
- Please be aware that there is a $25 fee* for copies of medical records from Kids First Pediatrics * This fee is waived if only immunization records are requested
Authorization to treat a minor
- Please fill the form out and submit it (Online) or fax it (printable PDF) to our office at (815) 609-8111 if someone other than the parent or guardian will bring the child into the office
- Please note that a parent or guardian must be present for immunizations to be given. We cannot accept this form for well-child visits.
Telemedicine Consent Form
Parent Letter on Adolescent Privacy