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Printable Forms

New Patient Registration Form

- Please fill in the information online and print it out and fax it to (815) 609-8111 or mail it to our office address listed above

Medical Release Form

- This is a form to release medical records TO Kids First Pediatrics

- Please fill in the information and forward it to your former provider.

- Please note that it may take a few weeks from the time that your former provider receives the request until we receive the records.

- Your former provider may charge a fee for photocopying the records

Release of Medical Records

- This is a form to release medical records FROM Kids First Pediatrics

- Please be aware that there is a $20 fee* for copies of medical records from Kids First Pediatrics

*This fee is waived if only immunization records are requested

HIPPA form

Authorization to treat a minor

- Please fill the form out and fax it to our office at (815) 609-8111 if someone other than the parent or guardian will bring the child into the office

- Please note that a parent or guardian must be present for immunizations to be given. We cannot accept this form for well-child visits.