For Life-Threatening Emergencies
Call 911

© 2016 by Mercer Island Pediatrics.

Patient Forms

Medical Records Release Form

 

Authorization form for MIPA to disclose records to third-parties

 

New Patient Packet

 

Registration form, financial policy and privacy practices agreements, and past patient/family medical history.

 

Please complete the family medical history with as much detail as possible -- we can use this information for reference over the course of your child's life. As with all other patient records, it will be kept confidential.

 

Change of Information Form

 

New address or insurance? Fill in your updated info on the registration form (you may leave other sections blank) and bring to your next appointment.

 

School/Camp/Sports Forms

 

Sports participation, med-at-school, and other forms for local school districts.

 

Please complete the patient/history portion of forms prior to exam appointment - doctors are unable to complete and sign until you have done so.

WA State Dept. of Health Medication Exemption Form

 

Form stating exemption from immunizations for religious, personal, philosophical, and medical reasons.

 

 

If you wish to have any forms mailed back to you, please provide us with a self-addressed and stamped envelope.