Mercer Island Pediatrics
9675 SE 36th ST, Ste. 100 | Tel: 206-275-2122
Mercer Island Pediatrics is and always will be a safe place. We believe in respect, kindness, and the right of every person to feel secure and valued.

SCHOOL FORMS
If your child is coming in for a clearance physical exam, the history portion of the form needs to be completed by the student and parent prior to the appointment.
Doctors cannot provide a signature of clearance without this information.
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​Don't see your form? Let us know so we can include it!
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WA State Forms
WA State DOH Immunization (Status, Exemption, etc.) forms
WA State DOH Certificate of Immunization Status
WA State HCP Orders for Diabetic Students
WA State Immunization Requirements, pre-school
WA State Immunization Requirements, K-12
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Auburn School District
MS Athletic Participation Medical Exam Form
HS Athletic Eligibility Packet - Exam Form on last 2 pages
Medication-at-School Authorization form
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Bellevue School District
HS Athletes Medical History and Physical Exam form
Individual Health Plan (standard) form
Individual Health Plan (severe allergy) form
Individual Health Plan (seizure disorder) form
Individual Health Plan (Type I diabetic) form
Individual Health Plan (Type I diabetic with pump) form
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Highline School District
Athletic Participation Physical Exam form
Athletic Return-To-Play (concussion specific) form
Camp Waskowitz Medication form
Individual Health Plan (diabetes) form
504 Plan Health Concern Verification form
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Issaquah School District
MS Athletic Participation Physical Exam form
HS Athletic Participation Physical Exam form
Summer Activity and/or Camp Physical Exam form
Elementary & MS Medication Authorization form
HS Medication Authorization form
Medication Authorization >72 hrs (disaster planning) form
Physician's Orders for Special Nursing Care
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Lake Washington School District
MS: Athletic Physical Exam Clearance form
HS Athletic Participation Medical History Form AND Physical Exam Form (both required)
Individual Health Plan (severe allergy) form
Individual Health Plan (asthma) form
Individual Health Plan (seizure) form
Health Care Provider Orders for Epinephrine Administration form
Tdap Form for Middle School Students
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Mercer Island School District
MS Athletic Participation Physical Exam form
HS Athletic Registration Packet
HS Injury Return-To-Play Clearance form
HS Return-To-Play (concussion specific) form
Life-Threatening Allergy Health Care Plan form
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Northshore School District
Athletic Participation History and Physical Exam form
504 Plan Eligibility Physician's Exam form
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Renton School District
Medication Authorization (asthma) form
Individual Health Plan and Medication Authorization form (allergy)
HS Athletic Participation Physical Exam form
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Seattle School District
Athletics Registration & Physical Exam form
Diet Prescription For Meals At School form
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Shoreline School District
Athletic Participation Physical Exam form
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​Snoqualmie School District
Diabetic Physician's Orders form
Insulin Pump Diabetic Physician's Orders form
Chief Kanim MS Athletic Participation Physical Exam form
Mount Si HS Athletic Participation Physical Exam form
Private Schools​
SAAS
Athletic Participation Physical Exam form
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