Forms
Record Request Form
Print, complete, sign and send this form to any other health care provider who may have medical records that will be helpful to your doctor at Tenth Street Pediatrics.
Print, complete, sign and send this form to any other health care provider who may have medical records that will be helpful to your doctor at Tenth Street Pediatrics.
| Release of Medical Records |
Record Release Form
Print, complete, sign and return this form to Tenth Street Pediatrics if you need your child's medical record. There will be a charge to copy and send your records.
Print, complete, sign and return this form to Tenth Street Pediatrics if you need your child's medical record. There will be a charge to copy and send your records.
| Authorization for Release of Information |
Adult Authorization Forms (For patients >18 years old)
| Adult Authorization (>18yo) |
Family Medical History Form
Print and complete prior to your first visit to our office
Print and complete prior to your first visit to our office
| Family Medical History |
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Administration Fee Form
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