Montessori Escuela, LLC

Parents First Name

Parents Last Name

Parent Email

Medical Form

Patient Information

Students Full Name:

First Name

Last Name

Middle Initial

Date

Pediatrician Contact Information:

Child’s Medical Form

Dear Pediatrician/Physician/Health Care Professional:

Montessori Escuela, LLC, by request of The Department of Early Education and Care, requires that all children/students who will be in a Large Group Montessori school child care program with other children, be examined by a pediatrician physician/health care professional, recent within one year of admission into the program. The department of Early

Education and Care’s regulations require at the time of admission a written statement from a physician as evidence of each child’s annual physical examination, immunizations and lead screening in accordance with Department of Public Health’s recommended schedules. A prompt response is appreciated. Evidence of a physical exam is valid one (1) year from the date the child was examined and must be renewed annually

thereafter. Your patient is required to submit this medical form as part of his/her school enrollment requirement. Please fill out the form in its entirety and return it to your patient.

Name of patient:

Date of birth:

Address:

Phone Number:

Date of Examination:

Name of Parents:

In your professional opinion concerning the child’s general health and appearance?

Does this child have any disabilities or chronic medical problems (allergies, limited vision, etc.) which require special consideration or care by the child care educator? If so, please detail below:

In your professional opinion does your patient have any limitations that would affect his/her ability to interact with other young children? If yes, please provide details of any of these limitations.

Comments:

Please answer the following questions:

1. Has this child been immunized in accordance with the requirements of the Department of Public Health recommendation schedule (Mumps, Measles and Rubella)?

Yes

2. Has this child had a complete physical examination within the past year?

Yes

3. Has this child been screened for lead poisoning?

Yes

(Pursuant to the department of Public Health requirements, all children, regardless of risk, must be screened for lead poisoning at least one (1) time between the ages of nine and twelve months, annually thereafter at the ages of two and three, and at age four if at high risk for lead poisoning)

If yes, dates screened:

Signature of Physician/Health Care Professional

Date

Please print your name

Telephone Number

License Number

*A traditional doctors note will suffice in lieu of this medical letter so long as vaccines & lead testing are shown. Please return this form and the child’s immunization via electronic record to:

Montessori Escuela, LLC

Medical Form

Patient Information

Child’s Medical Form

Montessori Escuela, LLC

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