Black Rock Pediatrics Registration Form
Prior to your first visit with Black Rock Pediatrics we ask that you print this form, fill it out and bring with you to your office visit. If you are not able to fill out the form prior to your visit please come in a few minutes early to complete all required paperwork.
Use this form to request release of medical records to be sent to Black Rock Pediatrics from your prior medical practice.
TB Risk Assessment Questionnaire
Use this questionnaire to assess your child's risk to exposure to TB.
Early Childhood Health Assessment Record
State law requires complete primary immunization and a health assessment prior to entering an early childhood program in Connecticut.
This form must be completed prior to school entrance in Connecticut. Please note that this form must be printed on blue paper.
This form is for campers and staff. Please return completed form to the camp. For purposes of this form physical exams are valid for 3 years from date of last examination.