About this template
A pediatric medical release form is an essential authorization document that allows pediatricians, clinics, and medical staff to treat minors or transfer patient health records. This free Google Form template helps medical practices collect secure, informed consent and records transfer requests from parents and legal guardians quickly and efficiently.
Designed specifically for pediatricians, family practices, and children's clinics, this form replaces slow paper processes and endless phone calls. Parents can easily provide their information, list their children's details, specify which medical records need to be shared, and sign off on disclosures from any device. With Doc2Form, you can instantly turn this template into a live Google Form, letting you streamline patient intake and maintain clear, documented authorization before any treatment or record transfer occurs.
Key features
- Collect parental consent and patient details in a single step
- Specify exactly which records need to be released or transferred
- Fully mobile-friendly for parents on the go
- Instantly convert into a live Google Form using Doc2Form
Use cases
Transferring a pediatric patient's immunization and physical records …
Transferring a pediatric patient's immunization and physical records to a new specialist
Obtaining parental authorization for ongoing pediatric care and treat…
Obtaining parental authorization for ongoing pediatric care and treatment
Requesting specific lab or imaging results disclosure from previous h…
Requesting specific lab or imaging results disclosure from previous healthcare providers
What this form collects
- Parent/Guardian Full Name (Short answer)Enter your full legal name as the parent or authorized legal guardian.
- Child 1 Full Name (Short answer)Enter the first child's full name.
- Child 1 Date of Birth (Date)Enter the date of birth for the first child.
- Child 2 Full Name (Short answer)Enter the second child's full name, if applicable.
- Child 2 Date of Birth (Date)Enter the date of birth for the second child, if applicable.
- Request Records From (Practice Name) (Short answer)Name of the doctor, clinic, or hospital releasing the records.
- Request Records From Contact Info (Paragraph)Provide the address, phone number, and fax number of the releasing practice.
- Release Records To (Practice Name) (Short answer)Name of the doctor or clinic receiving the records.
- Release Records To Contact Info (Paragraph)Provide the address, phone number, and fax number of the receiving practice.
- Information to be Released (Checkboxes)Select all types of medical records you authorize for release.
- Purpose of Disclosure (Dropdown)Select the primary reason for requesting this records transfer.
- Authorization Expiration Date (Date)Date when this release authorization expires.
- Authorized Representative Signature (Short answer)Type your full legal name to serve as your electronic signature.
- Signature Date (Date)Enter today's date.
FAQ
What is a pediatric medical release form used for?
It is used by healthcare providers to obtain written authorization from a parent or legal guardian to treat a minor or to transfer confidential medical records between facilities.
How do I share this form with parents?
Once you convert this template using Doc2Form, you can share the Google Form link via email, text message, or embed it directly on your clinic's website.
Can parents fill out this form on their mobile phones?
Yes, Google Forms are fully responsive, allowing parents to easily review and complete the form from their smartphones or tablets.
What information is collected in this form?
The form collects parent and child details, previous and receiving medical practice information, specific records requested (such as immunizations, physicals, or lab results), and authorization signatures.
How can I customize the questions?
After generating your form with Doc2Form, you have full access inside Google Forms to add, remove, or modify any fields to fit your practice's specific requirements.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.