You can access most of our forms at the links below, enter the information online directly onto the form, save and submit the form and it will be sent securely to us.
Or, we have also provided our office forms as a PDF in case you wish to print and complete the forms manually, If so, please either email them to [email protected] or bring them with you to your child's first appointment.
If you have any questions, please call our office at 650-321-9555 and our staff will assist you in preparing for your child's first visit.
Completion of new patient forms prior to your first appointment will help to expedite the registration process.
New Patient Forms
- Patient Demographic Form [Online] [PDF]
- Communication Consent Form [Online] [PDF]
- Bank Transfer Authorization Form [Online] [PDF] Or Preauthorized Credit Card Form (includes 3% credit card surcharge) [Online] [PDF]
Need to Transfer Medical Records to Burgess Pediatrics?
For families transferring care from another practice, please complete the following medical record release to have your records transferred to our office.
Leaving or Moving?
We are sad to see you leave! Please fill out the below form if you will no longer be a patient of ours so we can make sure your new provider has your past medical records. We are happy to send them directly to your new provider or mail them to your home.
Authorization for Release of Protected Health Information
- Permission for Physicians to Discuss Medical Information For patients 18 years and over [Online] [PDF]
- Permission for Physicians to treat patients 18 years and over [Online] [PDF]
Receiving a Covid Vaccine?
In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it: