Patient Form Submission

Patient Form Submission
Turnaround time for forms is 3 business days (Mon-Fri). If you have multiple children, please fill out a separate form for each child.
Patient Information
Patient Name: *

First Name Last Name
Patient Date of Birth: *

Month Day Year
Date
Email (to receive completed form): *

Confirmation Email example@example.com
Expedited
Requested Forms
Select all that are needed: *

Sports Form Camp Form Individualized Health Plan (IHP) Medication Authorization Immunizations ONLY Other (such as FMLA, adoption, etc.)
If your child’s form requires ONLY their immunization history, this digital forms workflow is not for you. Instead, please fill out this Authorization to Release Immunization Records form so that we can send you a copy of your child’s Certificate of Immunization Status (CIS). CIS reports do not include a provider signature but are a verified record of their immunization history and are accepted by all schools and camps. If you are submitting a school sports form or a camp form that includes your child’s immunization history, you do not need to complete a separate Authorization to Release Immunization Records form.
Information required for the completion of Sports, Camp, and/or IHP forms:
Have you had a wellness check-up in the last year (or 2 years if your form allows)? *

Yes No Unsure
Have you had a wellness check-up in the last year (or 2 years if your form allows)? *

Yes No Unsure
Medical History
Has your child been hospitalized or had a major injury or illness since their last wellness visit? *

Yes No
Approximate date of hospitalization or major illness: *
Please describe hospitalization or major illness: *
COVID-19
Has your child ever had confirmed or suspected COVID-19 infection? *

Yes No
Did your child have 4 or more days of fever (≥ 100.4), significant muscle aches/fatigue? *

Yes No
Was your child hospitalized? *

Yes No
Is your child still experiencing any chest pain, shortness of breath, dizziness with exercise, new heart palpitations, or new fainting? *

Yes No
Family Medical History
Have there been any significant new medical diagnoses in your family history? *

Yes No
Who was diagnosed? *
Age at diagnosis: *
Explain the new medical diagnosis: *
Other information: *
Add another family member and diagnosis
Who was diagnosed? *
Age at diagnosis: *
Explain the new medical diagnosis: *
Other information: *
Add another family member and diagnosis
Age at diagnosis: *
Who was diagnosed? *
Explain the new medical diagnosis: *
Other information: *
Are there any medications, including over the counter (OTC) products, your child will need authorization to take while at camp? *

Yes No
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Information required for the completion of Medication Authorization forms:
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Add another medication
Name of prescription or over the counter (OTC) medication: *
Dose: *
If you are requesting authorization for a prescription medication that was prescribed by an Allegro doctor, do you need a refill? *

Yes No
Preferred Pharmacy: *

Pharmacy Name

Street Address

City State
An in clinic Well Child Check-up is required every 1-2 years in order for our providers to ensure your child is in physically fit to participate in activities. Please schedule an appointment with your child’s Primary Care Provider (PCP). Don’t forget to bring any forms to the appointment.

Schedule Appointment
Any extended paperwork (FMLA, adoption, etc.) requires a visit with one of our providers. Follow the link below to schedule an appointment. Virtual Visits work well for these types of appointments. Don't forget to bring any forms to your appointment.

Schedule Appointment
Please sign into your child’s Patient Portal account to view the date of their last Well Child Check-up. If you do not have a Patient Portal account, please click this link to register.

Patient Portal
I already submitted my child’s school, sports, camp, medication, and/or IHP form(s) at one of the Allegro clinic locations.

Yes No
Upload Form(s)

A copy of all requested forms must be submitted. Failure to upload the necessary documents will cause a delay in processing.
Sports Form: *

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancel of
Camp Form: *

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancel of
Individualized Health Plan (IHP) *

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancel of
Medication Authorization: *

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancel of
Other Forms:

Only PDF files will be accepted. We recommend using a laptop or desktop computer to upload all forms.
Cancel of
Rush Processing

You will receive the completed form(s) securely via the email you provide within 3 business days, Monday - Friday (excluding holidays). If you need a form completed faster than our normal processing time, a rush fee of $20 per form will be charged for delivery within 1 business day, Monday - Friday (excluding holidays).
Would you like one or more of your forms expedited for a cost?

Yes No
Payment
Please select all the forms you want to have expedited:

Sports Form Camp Form Individualized Health Plan (IHP) Medication Authorization
Calculation Total 1
Calculation Total 2
Payment Due:

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