Does Your Child Need a Form for School, Sports, or Camp?
If your child has had a check-up within 1 year at Kaiser, we can complete a form for you.
If your child has NOT had a check-up within 1 year, please book an appointment for a check-up through your
kp.org account or the Call Center at 415-833-2200
2238 Geary Blvd., 5
th
Floor / Geary Campus
1600 Owens St., 3
rd
Floor / Mission Bay Campus
Complete the forms request intake form below
Complete the forms request intake form below
Complete the parent part of the form before submitting
the form.
Complete the parent part of the form before submitting
the form.
Forms are usually processed within 3 business days.
Forms are usually processed within 3 business days.
You May Submit Your Form & Intake Form By:
You May Submit Your Form & Intake Form By:
a. Email: sfpedforms@kp.org
a. Email: sfpedformmissionbay@kp.org
c. Drop Off in Person: 2238 Geary, 5
th
Floor
c. Drop Off in Person: 1600 Owens Street, 3
rd
Floor
Completed forms can be returned to you by:
Completed forms can be returned to you by:
a. Mail: forms will be mailed within 7 business days,
unless otherwise indicated.
a. Mail: forms will be mailed within 7 business days,
unless otherwise indicated.
b. Fax: if you want form faxed, you must also complete
and sign the release of information below.
b. Fax: if you want form faxed, you must also complete
and sign the release of information below.
c. Email: if you want form emailed, you must also
complete and sign the release of information below.
c. Email: if you want form emailed, you must also
complete and sign the release of information below.
d. Pick Up: You will receive a telephone call when the
form is ready for pick up on 5
th
floor, 2238 Geary Blvd.,
Monday to Friday 9:00a.m. – 5:00p.m.
d. Pick Up: You will receive a telephone call when the
form is ready for pick up on 3rd floor, 1600 Owens
Street, Monday to Friday 9:00a.m. – 5:00p.m
Forms Request Intake Form *** PLEASE PRINT CLEARLY ***
Address/City/State/Zip Code:
What is the best phone number to contact you?
How would you like to get your completed form returned to you?
[ ] Will pick up form
[ ] Please mail form to address above
Please Attach Your Form
(Make sure form includes your child’s name,
and any parent part is completed.)
[ ] Please fax form OR [ ] Please email form (Originals will be mailed)
If You Want The Form Faxed or Emailed PARENT CONSENT IS REQUIRED.
I am the parent of __________________________________________ and hereby authorize Kaiser-San Francisco
to fax / email the requested form to
(name of child)
___________________________________________________ at
(name of person, school, or office)
[ ] fax number: ________________________________________
[ ] email address: ____________________________________ @ ______________________________
______________________________________________ _______________
(Parent signature) (Date)
*FOR OFFICE USE ONLY: FORM COMPLETED: ( ) YES ( ) NO
COMMENTS: PediFormReq English 03/2016
click to sign
signature
click to edit
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