If you need more information or you have a general question, call us at 392-2077 ... or click here.

Forms

Listed below you will find some commonly needed forms for school and daycare, as well as some charts and forms we use to keep track of medical information.

Feel free to download and print any of these forms.  Please complete as much as you can yourself, before giving it to us.

We can return the completed form to you by fax.  If you give us a self-addressed, stamped envelope, we can mail the completed form back to you (or to the school).  Or you may pick it up when it's ready.

There is no charge for completing routine forms, if you bring the form with you at the time of the child's check-up.  We must charge $10 for completing routine forms given to us during a sick visit, or between visits.
 


  • Asthma "action plans" are sometimes required by school nurses, so that they have instructions when a child starts wheezing.  These forms must be signed by the doctor.

  • Asthmatic children can benefit by keeping track of Peak Flow Meter readings over time.  You may want to print this form, and show us the data you collect.

  • If you worry that your child doesn't eat enough, here's a sheet to count calories.

  • If your child attends a licensed day care in Delaware, you must fill out the top portion of this form and give it to us to complete.

  • Delaware schools must collect a doctor's form for each high school student involved in school sports.  Please fill in as much information as possible (such as the child's name, address etc.) before bringing it to us for signing.  (This form is updated for 2016 and after.)

  • This is the school physical form for entry into Delaware elementary schools.

  • Instructions to care for the ears, after we perform piercing.

  • To give permission for us to perform ear piercing, print and sign this form.

  • It is useful for me to have a brief list of family illnesses.  You  can complete this form and bring it to your first visit.  Check with all your close relatives!

  • If you decide to delay or decline routine vaccinations, we will ask you to sign this waiver.

  • If your baby is jaundiced and we discussed drawing bloodwork, print this form.  Fill in the name and birth date, and bring it to your lab.

  • Are you transferring your child's care to my office from another doctor?  You may download this form, and send it to your previous doctor.  (They may charge a fee for copying records.)

  • Please read our policy regarding our expectations of family financial obligations towards our office.

  • A skin test for Tuberculosis (PPD) is required for all new school entrants.  The skin test must be checked 48-72 hours after we plant it.  If the school RN is willing to check the reaction, please ask her to complete and fax this form to us.

  • New to our practice?  Here's an introduction to the office, and some forms to fill out.  Please print and complete these pages, and bring them to your 1st visit.