School / Daycare Forms

Most schools and daycares will require your child’s pediatrician to complete
health forms for enrollment purposes.

Please submit the form below so that we may help you in this process. Note that your child must have had a well-child checkup in our office within 365 days (1 Year) in order for us to complete the forms. If you need a sports physical form completed, the checkup must be after May 1st of the current year through June 30th of the succeeding year. If your child has not been seen according to these regulations, then please call our office to schedule a well-child or sports physical appointment.

Download and fill out the forms below before submitting them for processing.

Private School / Daycare Forms

Virginia Public Schools Physical Form

DC Public Schools Physical Form

Sports Physical Form

Immunization Records Only (No Charge)

Submit School / Daycare Forms

Use the form below to submit School / Daycare Forms for processing. Please be sure to fill out all the fields.

Name(Required)

First Last

Email(Required)

Phone(Required)

How soon would you like the form to be returned to you?(Required)

Expedited (Processing time is up to 3 business days and there is a $20 charge.)

Regular (Processing time is 5-7 business days and there is a $10 charge.)

How would you like the form returned to you?(Required)

Patient Portal

Call for pickup

Have you signed the consent for Email Communication of Health Information?(Required)

Yes

Email Communication of Health Information

EMAIL COMMUNICATION OF HEALTH INFORMATION

FACT SHEET AND CONSENT FORM

As a patient of Metropolitan Pediatrics, you may request that we communicate with you via unencrypted electronic mail (email). This Fact Sheet will inform you of the risks of communicating with your healthcare provider via email. Your health is important to us, and we will make every effort to reasonably comply with your request to receive communications via email. However, we reserve the right to deny any request for email communications when it is determined that granting such a request would not be in your best interest.

PLEASE READ THIS INFORMATION CAREFULLY

Metropolitan Pediatrics staff will make every effort to promptly respond to your requests for information via email. However, if you are experiencing an emergency, you should never rely on email communications and should seek immediate medical attention.

Risks of using email to send protected health information include, but are not limited to:

Risk of Unauthorized Access by a Third Party: Do you share a computer with your family? Is your email address or access to email provided through your employer? Do you access your email over an unsecured connection such as public Wi-Fi? Do you access your email on your mobile device? Emails may be accessed by someone you do not wish to know about your health information. Despite necessary precautions, email may be sent to the wrong address by either party. Email may be intercepted or altered in transmission by a computer hacker or computer virus.

Unique Difficulty in Verifying the Sender: Email may be easier to forge than handwritten or signed papers. Metropolitan Pediatrics will only send emails to the email address you provide, but it may be difficult to confirm that you are in fact the person sending the request for information from your email address.

Procedures

Emails are not checked outside of normal business hours – this includes overnight, on weekends or holidays.
If at any time you change your email address or wish to discontinue email communications altogether, you must notify Metropolitan Pediatrics immediately in writing.

EMAIL COMMUNICATION OF HEALTH INFORMATION

FACT SHEET AND CONSENT FORM

PARENT/GUARDIAN CONSENT TO UNENCRYPTED EMAIL COMMUNICATIONS

Consent(Required)

I consent

By signing below, you acknowledge your recognition and understanding of the inherent risks of communicating your child’s health information via unencrypted email and hereby consent to receive such communications despite those risks. Messages containing clinically relevant information may be incorporated into the medical record at the provider’s discretion.

Consent(Required)

I consent

By signing below, you also acknowledge that you have the choice to receive communications via other more secure means such as by telephone or in-person. By signing below, you agree to hold Metropolitan Pediatrics harmless for unauthorized use, disclosure, or access of your child’s protected health information sent to the email address you provide.

Child's Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Parent / Guardian Email #1(Required)

Parent / Guardian Email #2

Parent / Guardian Name Giving Concent(Required)

First Last

Relationship to Child(Required)

Signature(Required)

Patient Information

Patient Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Does your child have Medicaid? If so, there is no charge for the form.(Required)

Yes

Submit Form

Form Type(Required)

Select form your are submitting for processing

Upload Form(Required)

Accepted file types: pdf, Max. file size: 12 MB.

Payment

We will require payment before we start working on these forms unless your child has Medicaid. Insurance companies cannot be billed for this charge. We charge $10 for processing each form and our processing time is 5-7 business days. If you need it expedited, our charge is $20 and it will take up to 3 business days. Please use the link below to pay the appropriate charge via the Online Billing Page. If you do not have the account number then please use your full name to make payment online.

Link for payment will be provided after form submission and in the confirmation email.

Name on Credit Card for Payment(Required)

First Last

Enter Name used on Credit Card to make payment

This field is for validation purposes and should be left unchanged.

School / Daycare Forms