Forms

Below you will find some forms you may need during your time with our office. To submit a form, please download it, either complete online or print out and complete manually, and return the form to our office via mail, fax, our office email (algerped@algerpediatrics.com), or in person.

These forms are also available at our office. Please stop by at any time during our open hours to request them.

18+ registry update

Please submit your updated address and contact information to our office once you turn 18.

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covid consent form (over 12)

Please bring this completed form to your appointment for the first COVID vaccine.

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information disclosure form

Please submit this form to share medical information with another party, such as a parent or guardian.

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sports physical form

Please complete the health history portion of this form and return it to our office to be signed by a doctor/nurse.

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covid consent form (under 12)

Please bring this completed form to your appointment for the first COVID vaccine.

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INFLUENZA FORM

Please bring this completed form to your appointment for the flu vaccine.

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Records release form

To have your records transferred to a different office or sent directly to you, please complete and submit this form.

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Disclosures

Below you will find our office notices and disclosures. They are also available at our office. Please stop by at any time during our open hours to request a copy.