PEDIATRIC FORMS Daly City ONLY

Pediatric Medical Secretary FAX: 650-301-4504

If you need a form filled out, please complete the parent section on your form as well as the following information in black ink and fax with your form to the number above:

� Immunization card � School form

� Sports physical form � Other

Child's name__________________________________

Kaiser medical record number___________________

Child's date of birth___________

Your name ______________________

Relationship to child________________

Daytime phone number_________________

Alternate phone number_________________

Email address_________________________

Home mailing address_______________________

Our goal is to complete this information for you within 5-7 working days. We will mail the form to your home. If you have any questions, please call 650-742-2050. Thank you.

Comments:___________________________________________________________________________

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