Naomi Sato, M.D. and Robyn Kimura, M.D., Pediatrics

900 Florin Road, Suite B
Sacramento, California 95831
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(916) 421-8245

Office forms patients can fill out in advance of a visit

Once you have made your initial appointment, you can save time by downloading and printing the following forms by clicking on the links below.  By completing these forms and bringing them with you to your first visit, you will help make your new patient registration process faster and get you in to see the doctor more quickly!  You can also enter your child’s basic contact information (demographics) by pre-registering online on our Patient Portal after calling our office. 

Demographics and Contact Preferences Form -- (for new patients and existing patients with updated or changed information) -- names, dates of birth, addresses, phone numbers, and contact information for the child and parents or guardian. Also authorizes other responsible parties (such as other family members or close friends) to bring child in for medical care if a parent or guardian is not available.

Medical History Questionnaire -- (for new patients who have not had a well visit with our doctors) -- a questionnaire about your child’s past medical and family history. In order to give your child the best care possible, it is important for us to review the details of any medical care your child has received as well as any past health issues.  Because of this, we require parents to either complete this questionnaire and/or obtain copies of their child’s previous medical records including immunizations from all former physicians and bring them (or have them mailed) to our office prior to scheduling the first well child exam (physical) with us.  Once the doctors review your child’s questionnaire and/or past medical records (this is done in a timely fashion once they are received), we will be happy to schedule a well exam appointment for your child.  We are happy to see your child for ill visits prior to completion of the past medical questionnaire or while awaiting medical records.

Health Insurance Privacy Act (HIPAA), No Show Policy, and Responsible Party Acknowledgment -- (for new patients and existing patients who have not received the most recent version of this form) -- this form summarizes patient rights to privacy of their health information (per federal law) and our office’s policy on missed appointments.

Pre-participation Sports Physical Questionnaire -- for children aged 10 and up who are or planning to participate in organized sports (school or recreational).  This questionnaire must be filled out annually.

Authorization of Release of Information TO our office -- this form gives another doctor’s office or hospital permission to release your child’s medical records (such as previous office visits, hospital admissions, immunization records, etc.) to our office.  Complete this form and hand-carry or mail it to the desired doctor’s office, clinic, or hospital.  TIP: after you have submitted the request for your child’s medical records, call our office about a week later to make sure we received the records.  If we have not, contact the outside facility to check on the status of your medical records request.

Authorization of Release of Information FROM our office -- this form gives our office permission to release your child’s medical records to another doctor’s office or authorized individual, for example when transferring care to another physician.  Complete this form and bring or mail it to our office. 

Please note:  If you are unable to view the forms, you may need to download Adobe Acrobat reader for free by clicking on the icon below.

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Outside forms you may need the doctor to fill out for your child

When bringing forms to the office for the doctor to fill out, please remember the following:

Blank forms will not be accepted.  Forms will only be accepted for completion if the child’s name and other information has been completed. Print the forms you need and fill out the parent section before you submit forms to our office. To assist you, links to commonly needed forms are listed below.

Turnaround time for form completion may be up to 7 business days.  Parents should realize that at certain times of the year we may receive many health forms in one week, and remember that each of these has to be carefully reviewed by a physician before it is released.  Parents are strongly advised not to wait until the last moment.

Forms will be held here for parents to pick up.  Because of Health Insurance Portability and Accountability Act (HIPAA) regulations, forms will be released to parents only.  If you would like a form to be mailed to the home address on file, please provide us with a self-addressed stamped envelope.

Most forms require the information to be based on an examination completed within 12 months of the date the form is completed or may require specific evaluations that may not have been performed at the routine physical (for example, sports vitals after running, asthma/allergy treatment plans, etc.).  An additional office visit may be required.  If your child has not had a physical within the past 12 months, our staff will assist you in scheduling one.

While our office does not currently charge for many routine forms such as school physical, sports physical, or medication forms, there may be a fee for more lengthy or specialized forms such as FMLA, or if “rush service” is needed (forms that need to be completed within 24 hours).  The office staff will notify you of any fees if applicable. Insurance companies do not reimburse for form completion and we do not bill insurance for completing any forms.

Physician’s Report - Day Care Centers (Child’s Pre-admission Health Evaluation) -- Health evaluation form required for admission to day care or preschool. http://www.cdss.ca.gov/cdssweb/entres/forms/English/LIC701.pdf

State of California Report of Health Examination for School Entry -- California public school form required for entrance into kindergarten/1st grade. http://www.dhcs.ca.gov/formsandpubs/forms/forms/childmedsvcforms/pm171a(bi).pdf

Sacramento City Unified School District Sports Physical form -- Sports physical forms are now linked to each school’s website.  Please visit your child’s school website and follow the links to the Sports Physical Form.

Sacramento City Unified School District Medication Authorization form -- SCUSD form required for medication to be given at school. http://www.scusd.edu/document/medication-authorization-form

Elk Grove Unified School District Sports Physical form -- EGUSD form required for participation in school sports (scroll down to “Sports Physical Exam”). http://blogs.egusd.net/athletics/forms/

Elk Grove Unified School District Authorization of Medication for Pupils -- EGUSD form required for medication for be given at school (scroll down to “Authorization of Medication for Pupils”). http://www.egusd.net/students-families/egusd-forms/

Please note:  If you are unable to view the forms, you may need to download Adobe Acrobat reader for free by clicking on the icon below.

get_adobe_reader

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