- QR codes for all forms are listed on this page.
- List of forms according to visit type.
- Forms related to vaccinations.
- Commonly requested forms, such as school sports physical forms.
You may also contact us at:
- Text message: (650) 994-3000
- Email: support@pedia.health
- You may use the Messenger button on this website, in the bottom right corner. No login required.
- Best way to manage your appointments with our practice is via Patient Fusion, the patient portal to your medical record.
- Otherwise, you may use the Request form on this page, or contact us by:
- Text message: (650) 994-3000
- Email: support@pedia.health
- You may use the Messenger button on this website, in the bottom right corner. No login required.
You may also contact us at:
- Text message: (650) 994-3000
- Email: support@pedia.health
- You may use the Messenger button on this website, in the bottom right corner. No login required.

Request

Your Name

First Name

Last Name

Mobile Phone (Text Messages)

(###)

###

####

Your relationship to patient.

Your Email Address

Requests

Check all that apply.

Immunization Record

School Sports Physical

New Appointment

Reschedule Appointment

Prescription / Refill

Other

Patient Name

First Name

Last Name

Patient's Date of Birth

YYYY

Additional Details

Forms

New Patient Forms

A new patient form is used by doctors to ask new patients to provide basic health information in writing. Doctors may want to ask for personal information, such as medical history, health insurance, or allergies.

Sports Physical Form

Your doctor will check your child's weight, height, flexibility, strength, joints, pulse, blood pressure, vision, and posture. The doctor will also check the throat, nose, ears, lungs, abdomen, and heart.

HIPAA Compliance and Patient Consent Form

HIPAA helps to ensure that any information disclosed to healthcare providers and health plans, or information that is created by them, transmitted, or stored by them, is subject to strict security controls. Patients are also given control over who their information is released to and who it is shared with.

Consent and Authorization of the Disclosure of Protected Health Information

The purpose of a consent form is to inform clients, patients, or subjects of what information you're obtaining, what rights they're waiving, and other pertinent details. They ensure that the lines of communication remain open among the parties and afford people the right to be informed.

Missed Appointments Form