Physician Certification
Health Status Indicators
Date:
Physician Name
Address
City, State, Zip Code
RE: __________________________________________ _______________
Child’s Name Date of Birth
Dear Dr. __________________:
This child is being served through the Infant & Toddler Connection of _____________. Please help us support this child and family by providing the information requested below. Once completed, please return this form to us at the fax/address listed at the bottom of this page.
Health Status Indicator Questions
1. Is this child up to date (per CDC/ACIP guidelines for this year) on immunizations? __ Yes ___ No
2. What is the date of this child’s most recent visit with you? ____/____/____.
3. What is the date of the most recent well child visit? ____/____/____.
4. What month/year should this child see you for the next well-child visit? ____/____.
5. Are there immunizations needed at time of next visit? ___Yes ____No
6. Does the child’s record have any lead testing (either capillary or venous) results? ____ yes ____ no If yes, date service provided ____/____/____ and testing results: ___normal ___elevated
*************************************************************************
THANK YOU!
____________________________________________________
Name/Title
Return this form to:
Name, address, city/state/zip code, fax number
................
................
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