Tenth Street Pediatrics
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Forms

Record Request Form
Print, complete, sign and send this form in order to release medical records. There will be a charge for us to copy and send records.
Release of Medical Records
File Size: 42 kb
File Type: pdf
Download File

Adult Authorization Forms (For patients >18 years old)
Adult Auth (>18yo)
File Size: 206 kb
File Type: pdf
Download File

Family Medical History Form
 Print and complete prior to your first visit to our office
Family Medical History
File Size: 15 kb
File Type: pdf
Download File

Administration Fee Form
2020 Admin Fees
File Size: 72 kb
File Type: pdf
Download File

Tenth Street Pediatrics
1450 Tenth Street, suite 304
Santa Monica, CA  90401
phone 310.458.1714
​fax 310.394.8754
​info@tenthstpeds.com
  • Home
  • Contact
    • Appointments
    • Telemedicine
    • Home Visits
    • Location
    • Policies
    • Forms
  • About Us
    • Who We Are
    • Doctors
    • Staff
  • Hours
    • Office Hours
    • After Hours
  • BILLING
    • Pay your bill
    • Insurance
    • Administrative Fee
  • Health Topics
    • Patient Handouts
    • Routine Vaccine Schedule
    • Child Health Topics
    • COVID-19 Updates
  • Media