American Kids Care – Pediatric Group

PRACTICE FORMS

• – New Patient Registration Form
• – Medical History Questionnaire
• – Notice of Privacy Practices
• – Record Release form
• – Covid-19 Vaccine Consent form

• – School Entrance Health Form (Commonwealth of Virginia) (MCH-213)
• – Epinephrine Authorization (SS/SE-64)
• – Medication Authorization (SS/SE-63)
• – Inhaler Authorization (SS/SE-65)
• – Sports Participation Form Jan 2021

---

WIC – WOMEN, INFANT & CHILDREN

• WIC – 395 form 6/21