FORM COMPLETION REQUEST – PEDIATRICS

Please review our policy and rules about school or other forms completion requests for your child:

  • Forms can be completed ONLY if your child had a well-child visit within the last 12 months OR as specifically indicated on your requested form
  • NYS Universal Health Examination forms (example) – accepted by all public schools, camps, afterschool programs and day cares in NYS. This can be accessed also via child health account or requested below (you do NOT need to upload the NYS Universal school form)
  • Any other form can be requested and UPLOADED below
  • Any portion of the form required to be filled out/ signed by a parent MUST be filled out by the parent BEFORE submission; otherwise it will be rejected.

Child’s first name (*) :

Child’s last name (*) :

Child’s DOB (*) :

Your Email (*) :

Parents’ first name (*) :

Parents’ last name (*) :

Reason for request :

Upload a file (Max size 5MB) :
Please DO NOT upload blank NYS Universal school form-those we have on file.
For any other form: Any section of your form required to be filled out/ signed by a PARENT MUST be filled out by the parent BEFORE upload; otherwise it will be rejected.



Please select the doctor who saw your child at the last well child visit (*) :

Select a mode of delivery:








Select the service (*) :
 Regular service –within 48 hours ($10) Priority service- within 24 hours (Mo-Fri)($25) Rush service –within 3 hours (Mo-Fri /9am-5pm must be ordered by 1pm)($40)

I have read, selected and understand the fee and my financial responsibility for this form completion request and agree to have my credit card on file at Apple Pediatrics charged the amount for the service I selected.

Please sign your request (*) :

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