Forms: School, Camp, or Daycare

Health forms are a necessary process when it comes to enrolling your child in school, sports, camp, or other physical activities. We are striving to make your lives easier when it comes to these forms. With our updated process you can expect the following:

• Easier completion & submission
• Faster turnaround time
• HIPAA compliant & secure
• Increased reliability from start to finish

Please be advised if you submit multiple forms for one child or for multiple children you may receive them at separate times or even on separate days. We have not forgotten about any forms submitted. All of your forms are in the queue to be completed and will be returned within 5-7 business days. Please do not email inquiring about your “other forms” if you have already received one of them unless it is beyond 7 business days from the date of submission.

Follow these easy steps:

1. Pick the correct health form below that pertains to your child
2. Electronically complete the parent section of the form
   • Required fields must be completed in order to submit your forms
3. Digitally sign your form and hit submit.
4. Check your email and verify your digital signature.
5. Immunization records are attached to all health forms and have a Potomac Pediatrics stamp. Due to the nature of this process, we do not “sign” the form but the stamp constitutes an official record.

After you’ve submitted your forms (via verifying your digital signature) they will immediately drop into our queue for completion. When your forms are completed, you will immediately receive a finalized copy in your email.

Do you need just an immunization record? If so please request this through the patient portal!

In order for Potomac Pediatrics to complete health forms for your child, they are REQUIRED to have a physical within the past 12 months. You can verify if your child is up to date by logging into your patient portal and checking their appointment history or by contacting our office. Any request for health forms received for a patient that does not have an up to date well exam will be declined. Forms submitted prior to a scheduled well exam will be held until the appointment occurs at which time we will complete the requested forms. Please note that completion will not occur at the time of the appointment.

COVID-19 Supplemental Questions Sheet

Bullis Health Forms

Bullis 2020-2021 Health Form

Bullis School Asthma Action Plan & Authorization

Bullis School Allergy Action Plan

Camp Forms

Capital Camps

Boy Scouts Camp

Camps Airy and Louise Medical Forms

JDS Health Forms

2020-2021 JDS Health Assessment Forms

2020-2021 JDS Sports Physical Forms

2020-2021 JDS Authorization to Administer Prescribed Medication Forms

2020-2021 JDS Non-Prescription Medication Authorization Forms

2020-2021 JDS Anaphylaxis/ Severe Allergy Action Plan Forms

JDS Asthma Action Plan (The ALA Asthma Action Plan form is the preferred form for JDS)

Maryland State Forms

Maryland State Health Inventory Form

(OCC1215) MD State Health Inventory Childcare Form (For most Daycares and PreSchools)

Maryland State Childcare Medication Authorization Form

Maryland State Asthma Medication Authorization Form

Maryland State Asthma Action Plan Form

Maryland State Lead Form

Maryland State Child Care Asthma Medication Administration Authorization Form

Maryland State Allergy Action Plan Form

Maryland State Emergency Form

Maryland State Medication Administration Authorization Form

Montgomery County Health Forms

MCPS R-6 Student Record Card 6

• If your child is entering an MCPS school for the first time or is entering Kindergarten, you will need to complete the MCPS Student Record Card.

MCPS Pre-Participation Form for Athletes- 2020

• This form includes the COVID-19 supplemental questions sheet.

MCPS Authorization to Administer Prescribed Medications

• On the cover sheet please specifically list the medication you are requesting this for this form.

MCPS Authorization to Administer Prescribed Medications (for children with multiple medications)

• If your child will need prescription medication or over-the-counter medication at school, you must complete one form for each medication. Please note this is a mandatory requirement per MCPS.

MCPS Epipen Authorization            Epipen Shortage Notice- Read More >>

Montgomery County Asthma Action Plan & Medication Authorization Form

Archdiocese Health Forms

Archdiocese Health Inventory Form

Archdiocese Inhaler Authorization Form

Archdiocese Allergy Action Plan

Archdiocese Medication Authorization Form

Miscellaneous Health Forms

Age of Consent Form/ Authorization to Release Medical Information

DC Universal Health Certificate Form

Georgetown Prep Health History Record 2017 School Year

Good Counsel Physical Exam Health Form

Green Acres OTC Medication Form

Montgomery Sports Association (MSA) Medication Authorization Form

American Lung Association Asthma Action Plan

BBYO Teen Medication Form

Is your school/camp form not available?

Email question@potomacpediatrics.com a blank PDF copy and we will review the form you’ve submitted. If there is a high enough patient demand we will build an online version within 14 days for future automatic submission. We thank you for submitting blank copies to our office, and ask that you still submit your non-electronic forms using the cover sheet and form submission option below. Please note, we will not be building out private school forms that are replicas of Maryland State Forms.

Health forms not available on our website through automatic submission may be submitted by completing the cover sheet below and attaching your forms. Please ensure the parent section is completed prior to submitting your forms. Failure to complete the cover sheet and/or parent section will result in your forms being rejected.

Please note that all forms may take up to 7 business days to be completed. We receive the highest volume of health forms April-August, resulting in completion times that may take the full 7 days. Forms are completed as they are submitted. There is no fast-track or expedited process for late submissions.

Patient Name:DOB:Today's Date:

Please Provide a Contact Number: Email:

please list the facility name and type of form (ex: BAR-T Camp Form, JDS School, etc.):

• Have you completed your portion of the forms? Yes
• Please ask if you’re unsure about what section you need to complete.
• Is your child currently taking any medications?    YesNo
1. If yes, please list all medications and dosages. Including any over the counter, herbal,vitamins, or sports supplements.




2. Will these medications be taken at school/ camp/ daycare? YesNo
3. If yes, are there specific times the medication needs to be given? Dosages?

• Does your child have any allergies to food or medications?  YesNo
1. If yes, please list below.




• Is there anything else that you would like the school/ camp or daycare to know about your child? YesNo
• Does your child wear eyeglasses or contact lenses?  YesNo
• Does your child wear braces?  YesNo

HOW WOULD YOU LIKE TO RECEIVE THE FORMS BACK?

Please select one option from below.

• Receive a call to pick upReceive a text to pick upMail (please provide mailing address)E-Mail (please provide email address)Fax* to School/Camp/Daycare Please do not select this option if you wish to review the formsprior to submission to school/camp/daycareFax* to Home/Work*Please Provide Fax Number

*I authorize Potomac Pediatrics to fax my child’s forms to the provided fax number above. Initial:

OFFICE USE ONLY RECEIVED BY: NCSF PAID?

Attach Form :