Patient Forms

We are happy to provide our office forms that may be filled out Online and securely emailed to our office (HIPAA 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

New Patient Packet - Printable PDF
New Patient Packet - Submit Online
Double Book Policy
Late Policy 
Refusal to Vaccinate Policy
Well Child Policy

Kid's First Pediatrics New Patient Registration Forms - Printable PDF 

Kid's First Pediatrics New Patient Registration Forms - Submit Online

Medical Release Forms

Medical Release To Kids First - Printable PDF 

  • 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

Release of Medical Records From Kids First - Printable PDF 
Release of Medical Records From Kids First- Submit Online

  • 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

Authorization to treat a minor - Printable PDF
Authorization to treat a minor - Online

  • 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

Telemedicine Consent Form - Online

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