School Forms Request

Child's Name

First Name(Required)

Last Name(Required)

School Name(Required)

Child's Date of Birth(Required)

Check All Forms That Are Needed ($10 Per Form)

School Form (Yellow Form)

Form D3040 (Yellow Form / Physical)

School Form (Blue Form)

Form D680 (Blue Form / Vaccines)

Athletic Form

(Archdiocese/Catholic Parochial School)

Athletic Form (All Other Schools)

(Form EL2)

Vaccination History (Free Of Charge)

Vaccination History

(NOT sufficient for SCHOOL ENTRY)

2nd Child's Name (If Applicable)

First Name

Last Name

School Name

Child's Date of Birth

Check All Forms That Are Needed ($10 Per Form)

School Form (Yellow Form)

Form D3040 (Yellow Form / Physical)

School Form (Blue Form)

Form D680 (Blue Form / Vaccines)

Athletic Form

(Archdiocese/Catholic Parochial School)

Athletic Form (All Other Schools)

(Form EL2)

Vaccination History (Free Of Charge)

Vaccination History

(NOT sufficient for SCHOOL ENTRY)

Contact Email(Required)

Contact Phone(Required)

Delivery Method(Required)

Delivery Speed

Total

BOOK AN APPOINTMENT TODAY!

Request an appointment

Our commitment to caring for your family is now available around the clock. Our physical office location may currently be closed, but you can still call (954) 752-9220 to speak with a trusted medical team member at our after-hours call center.

If you are experiencing a medical emergency, please call 911.

Please note: At this time, our office does not provide medical exemptions for masking where mandated.

Our providers and staff support mask mandates, especially in school settings, to effectively and safely prevent the spread of COVID-19.

Your child's health is our priority!