FARMINGTON PEDIATRIC & ADOLESCENT MEDICINE © Copyright

Designed and supported by The Verden Group 

PHOTOGRAPHY BY LINDSAY RIVERS 

At your well child visit you will be provided with a completed State of Connecticut school form, Health Assessment Record (HAR), and an immunization record for your child. In school aged children, we will also provide a State of Connecticut Camp form which is valid for 3 years.  These may be used to satisfy requests for forms from schools, camps, or sports activities anytime within the next 12 months. Please complete all of the parental & patient sections of forms prior to your child’s visit.

We encourage you to make and hold onto multiple copies.  When you receive a request from a school, camp or athletic organization, you should attach these copies to their request for medical information.  All of the information that is needed to satisfy their requirements is included within these documents.  Providing them to your school or camp should eliminate the need for you to forward a specific form to us and then wait for our office to complete your form(s).

We are providing you with this copy free of charge at the time of your child’s well exam.

If your camp or school will not accept the information in this format and you still need to have their form completed, there will be a $10.00 charge for each form. Payment is due when the forms are dropped off. We have a 7 day turn around time for forms.  

Please understand that each separate form that we need to complete takes time both on the part of the staff to fill out as well as by our Providers to review, amend, and sign. To that end, we are hopeful that this minimal charge of $10.00 per form will not be an undue burden to you while allowing us to continue providing quality care we deliver with minimal disruption to our staff.  All additional form requests will still require a week for completion. 

Rush forms for same day will incur a fee of $20.00 and if we have to mail it back to you there is an additional $1 charge. Forms cannot be faxed.

College forms require a week for completion and there will be a $10 charge, regardless of whether they are presented at the time of a health maintenance visit.

We hope this policy will provide you with timely access to the medical information that you need for your child’s activities.

Sincerely,
Your Healthcare Team at Farmington Pediatric & Adolescent Medicine, LLC.

 NEW PATIENT Forms  CAN BE FOUND HERE

1 Forest Park Dr | # 1

Farmington | CT 06032

TEL: (860) 677-1112​​

​​​FAX: (860) 674-9442​​

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School, Sport & Camp Forms Policy