Medical Record Request

Please fill out this form to have your child’s medical record sent to Greater Cleveland Pediatrics. Once submitted, the completed form will be sent to us and we will fax it to your previous pediatrician on your behalf. The most important information for us is your child’s vaccine record, growth chart, last well visit note, and notes about any chronic conditions.

Social Media Consent

This form allow you to choose how photos or videos of your child may (or may not!) be used by Greater Cleveland Pediatrics. Don’t worry, only fun photos and videos would ever be taken and would only be used for the purposes of showing how great it is to be a patient of Greater Cleveland Pediatrics! (This form is optional).

Past Medical Record

We are asking for all parents to complete this form which will provide Drs. Keili and Allie with a complete record of your child’s medical history. Even if your child is a past patient of ours, it is helpful to make sure that we have every detail right. Our goal is to provide your child with the most personalized care and this information will help us to do so.

Greater than 18 year old Consent

This form needs to be completed by all patients who are older than 18 years of age. Now that you are officially an adult, it is time to take control over your medical information! This form will specifically guide us regarding which information we are allowed to share (or not share!) with anyone (i.e., parents) who is not the patient.

Consent to Accompany a Minor

We need this form so that we know who is permitted to bring your child to see us in your absence. This would include nannies and grandparents. We will always do our best to call you during the appointment, but in the case we can’t reach you, this form grants this person your approval to consent to our recommended treatment or testing.

Prenatal Information Form

This form should be completed prior to the birth o of your new baby. It will be used by Drs. Keili and Allie to help us prepare for the arrival of your baby and make sure that we have as much information as we can ahead of time to make the arrival of your newest addition as smooth as possible!