Forms

Forms, forms, forms!

We are happy to complete day care, WIC, school, camp, and sport participation forms as well as immunization cards for your children at no charge. If you bring the forms to a well-child/physical visit, we will attempt to fill them out before you leave. If you bring forms at other times, please allow one week for completion. Please provide an addressed envelope if you would like us to mail you the completed form.

You may also e-mail a request to have your child's school or sports form completed. In your email, please include your child's name, date of birth, what type of form (or attach your institution's required form), your name, which office your child is seen at, and your best contact phone number.

We will charge a “rush” fee of $25 if you need forms in less than one week. There is also a fee for forms and immunization records completed a second time.

Commonly used school forms

School Entry Health Examination Report

Child Care Health Form

High School Sports Pre-participation Form

Helpful Questionnaires 

Edinburgh Postnatal Depression Scale a screening tool to assess for the likelihood of Postpartum Depression (the most common complication of childbearing) 

MCHAT a parent report screening tool used to assess the risk of Autism Spectrum Disorders (ASD)

PHQ-A a questionnaire that helps assess the level of depressive symptoms in adolescents 

Business forms

Registration and Authorization Form

Release of Records Authorization (from others to Kiwi)

Release of Records Authorization (from Kiwi to others)

Adult Patient Registration Form

Patient Registration Form (Spanish)

Kiwi Feedback Form

Office Hours

Alcatraz Ave Office

Monday - Friday:

9:00 am - 5:00 pm

Saturday:

See San Pablo Office

Sunday:

Closed

San Pablo Ave Office

Monday - Friday:

9:00 am - 5:00 pm

Saturday:

9:00 am - 12:00 pm

Sunday:

Closed

Our Location

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