Forms

Forms

General Patient Forms


Medical Records Release

Please note: if you are planning a move out of the country, please request your child's records using this form prior to your departure


Asthma Materials


Nexplanon Materials 


Immunizations

Most schools and daycares in Washington State require a Certificate of Immunization Status (CIS) form for enrollment. Please allow two business days for our office to complete requests for immunization records or CIS forms.

The doctors in our practice know that vaccines, or immunizations, save lives. Immunizations prevent complications, disability, hospitalization, and death from disease. We are committed to discussing vaccinations and preserving relationships with families who decline or alter the recommended vaccine schedule. However, we do ask that these families sign a Refusal To Vaccinate Form to acknowledge acceptance of responsibility and potential consequences of vaccine refusal.

The Washington State Department of Health also has a Certificate of Exemption Form that must be provided to the child’s school or child care when requesting exemption from vaccines for personal, philosophical, religious, or medical reasons.

Visit our Childhood Immunizations page for more resources about immunizations.


School, Sports, and Camps

Please allow two business days (excluding weekends & holidays) for forms to be completed by an Allegro provider.

Sports Physical or Camp Health Forms

  • Physical/Medication Form 
  • To ensure that any health conditions are identified and addressed appropriately, the  Health History Questionnaire must be completed before a physical health form is signed by your doctor (if your child has not had a full wellness exam within the last 6 months)

Medication Authorizations 

Requirements vary by school district and program. Please confirm required forms and deadlines before scheduling an appointment. Links to the various Eastside school districts can be found here.


eTravel Clinic 

Allegro Pediatrics offers pre-travel health consultations that are online, affordable and convenient. The eTravel service is offered at a cost of $60. Please note that, while we will bill your insurance, you will be responsible for this amount if the service isn’t covered.

Submit your completed eTravel Questionnaire to us either by fax or by dropping it off at any of our eight offices. Learn more here.


Well Child Check-up Screenings

Patient Health Questionnaire-2 (PHQ-2)

The postpartum period can be difficult for some parents. Your health is important for the health of your baby. The Pediatric Health Questionnaire-2 (PHQ-2) helps us screen for postpartum depression so that we can offer support if there are concerns. This short assessment is best completed by the patient’s biological mother, when available.

M-CHAT-R

The M-CHAT-R is a developmental screening tool for toddlers at their 18- and 24-month well check appointments. It is designed to identify children who may benefit from a more thorough developmental evaluation.

Pediatric Symptom Checklist-17 (PSC-17)

The Pediatric Symptom Checklist-17 (PSC-17) is a screening tool used to identify potential behavioral health concerns in children. Allegro providers use this routinely at all 6- through 11-year-old Well Child Check-ups.

Patient Health Questionnaire-9 (PHQ-9)

The Pediatric Health Questionnaire-9 (PHQ-9) is a screening tool used at all Well Child Check-ups for children 12 years and older to identify concerns with depression. The patient should answer these questions, but the parent/guardian may help as needed.

CONFIDENTIALITY

Washington State has special protection for patient confidentiality starting at the age of 13. Your provider would like to take this Well Child Check-up as an opportunity to demonstrate Allegro Pediatrics as a safe place for your teenager to talk about anything they feel is important to their health and to encourage more independence for their own health care. If you and your teen feel comfortable, we invite your teen to fill out these forms confidentially and at the appointment, your provider will review the forms with your teen.


Academic/Behavioral Concerns

These forms may be requested before an appointment for academic/behavioral concerns for school-age children and teens. If requested, please fax the form to the clinic where your appointment is scheduled, 48 hours before your appointment.