Forms

Change of Address Form
If you have moved or your phone number has changed, please use the link below to fill out a form to let us know your new address and phone number.
Click here to fill out a change of address form online.

Health Form
A health form is the most recent report of your child's latest physical exam and contains his or her record of immunizations. It is usually required by camps or schools before your child attends. Most camps and schools require that your child have had a physical examination within the 12 months preceding attendance.

Our policy has changed effective July 1, 2008, there is no longer a charge for receiving a yearly health form. This may now be requested at the time of your child's well visit or by faxing us the request form. If we are unable to process this at the time of your child's visit we will fax it to you by the next business day, you may return the following day to pick it up or you may leave a stamped, self-addressed envelope for us to mail this to you. If you request additional copies during the year, there will be a $10.00 processing fee.
Click here to download a printable (PDF) copy of the request form.

Referral Request Form
Below is a link to our online referral request form as well as links to important information about the referral process.
Online Referral Request Form
Download Printable Form (pdf)
How to Request a Referral
The Truth About Referrals

Medical Record Release Form
Below is a link to a printable (PDF) copy of our Medical Record Release Form as well as a link to instructions on where to send this form.
Download Printable Form (pdf)
Medical Record Release Instructions

Parent Permission Form
The Parent Permission form should be filled out when you wish to allow someone, other than a parent, permission to bring your child for care at Centre Pediatric Associates, PC.
Download Printable Form (pdf)