Medical Records & Forms

Patient Form Submission

We encourage all patients to bring any necessary forms with them to their annual Well Child Check-up.

All form completion requests, including Sports forms, Camp forms, Individualized Health Plans (IHP), and Medication Authorization forms, received outside of a scheduled visit must be submitted electronically using our Patient Form Submission request page. There is a charge for the processing of all forms not brought into clinic at the time of a scheduled appointment, as this is an additional service provided by our staff and providers. Pricing is as follows:

• Standard Processing | 5 business days, excluding weekends & holidays
  • 1 Form: $15
  • 2 Forms: $30
  • 3+ Forms: $40
• Expedited Processing | 1 business day, excluding weekends & holidays
  • Above pricing plus $30 rush processing fee

Please note that our providers are only able to fill out forms for your child if they have been seen in our office for a Well Child Check-up within the last year, or two years if their form allows. Please schedule a Well Child Check-up with your child’s Primary Care Provider (PCP) if your child hasn’t been seen within the requirement on the form and bring any forms you need completed with you to the visit. You can find the date of your child’s last Well Child Check-up on their Patient Portal account.

We kindly request that you do not drop forms off at our clinic front desks, as our receptionists will direct you to submit a form request online.

Please visit our School, Sports, & Camp Physicals page for more information and for links to local school district forms.

Any extended paperwork (FMLA, adoption, etc.) requires a visit with one of our providers. Visit our scheduling page to book an appointment. Virtual Visits work well for these types of appointments. Don't forget to bring any forms to your appointment or submit via your Patient Portal.

Immunization Records Request Form 

Most schools and daycares in Washington State require a Certificate of Immunization Status (CIS) form for enrollment. Please complete the Immunization Records Request Form above and allow 7-10 business days (Monday - Friday) for our office to complete requests.

The doctors in our practice know that vaccines, or immunizations, save lives. Immunizations prevent complications, disability, hospitalization, and death from disease. Visit our Childhood Immunizations page for more resources about immunizations. 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. Please schedule a visit with your child's primary care provider (PCP) if you need a Certificate of Exemption Form completed that requests exemption from vaccines for personal, philosophical, religious, or medical reasons.

• New Patient History Form
• Health History Questionnaire (Now an editable PDF! Please download and save to your computer before filling out.)
• Notice of Privacy Practices
• Notice of Privacy Practices Acknowledgement
• Consent for Care
• Financial Responsibility Agreement
• Synagis Consent Form (New Online Form)
• HIPAA Release for Patients 18 and Older

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.

Authorization to Leave Patient Health Information by Alternate Means

The Authorization to Leave Patient Health Information by Alternate Means allows patients starting at the age of 13 to be contacted directly about test results. It also allows patients to designate which, if any, parents/caregivers can receive certain health information.

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.

• 13-year-old and above Well Child Check-up: PHQ-9 and Teen Questionnaire
• Authorization to Leave Patient Health Information by Alternate Means

Forms for academic/behavioral concerns can be found at the bottom of our Behavioral Health page under Behavioral Health Questionnaires.