Welcome to Apple-a-Day Pediatrics, S.C. Below are the patient forms you may need before or during a visit. Click any form to open or download the PDF. Please print, complete, and bring the completed form to your appointment.

Registration Forms

• Patient Policies – HIPAA acknowledgement, consent for treatment, financial agreement (revised 5.2026)
• Registration Form — Child Under 18 – new patient intake for patients under 18
• Registration Form — Adult (18+) – new patient intake for patients 18 and older, includes release consent

Medical History

• Pediatric Health History Questionnaire – complete before your child’s first visit or annual physical

Privacy & Consent

• Notice of Privacy Practices – how Apple-a-Day uses and discloses your child’s health information (revised 4.2026)
• Telemedicine Consent – consent for video and phone visits
• Flu Vaccine Consent – required for any seasonal influenza vaccination

Physical Exam Forms

• Sports Physical Form – IHSA pre-participation examination for school sports
• School Physical Form – Illinois Certificate of Child Health Examination, required for school enrollment

Risk Assessments

• Pediatric TB Risk Assessment – tuberculosis screening questionnaire
• Childhood Lead Risk Questionnaire – required for ages 6 months through 6 years for daycare, preschool, and kindergarten

Medical Records

• Medical Record Release / Authorization – authorize sending or receiving medical records (revised 8.2025)

Questions about any of these forms? Call our office at (630) 554-7654 or message us through the patient portal.