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.