Printable Forms

We are happy to offer you the option to download, print and complete our office forms to reduce wait times during your appointment.

Forms for New Patients (Including Newborns)

(In addition to the forms directly below, please complete the form(s) in the "General Forms for All Patients" specific to patient's age if patient is coming in for a well exam.)

Forms for Newborns Only

General Forms for All Patients

Exam for 1-month-old, 2-month-old, 4-month-old and 6-month-old:

Exam for 9-month-old:

Exam for 12-month-old:

Exam for 15-month-old:

Exam for 18-month-old:

Exam for 2-year-old:

Exam for 2 1/2-year-old (30-month-old) :

  • ASQ-3 (Must be completed electronically)

Exam for 3 through 6-year old:

Exam for Kindergarten:

Exam for 7 through 9- year-old:

Exam for 6th Grade, the 9th Grade/HS Freshman:

Exam for 10 years and over:

Patients 18 years old and over:

Information for College Students about Meningococcal B and Meningococcal Conjugate-As of 2018, some states, including Indiana,* require all students attending residential campuses at colleges to be immunized against Meningococcal disease by receiving the following vaccines:

  • Meningococcal Conjugate-one dose on or after 16th birthday
  • Meningococcal B (Brand name-Trumenba)-2 doses 6 months apart or thereafter for students 10-25 years old

*Check with your school before attending for their requirements.

Beyfortus (RSV Shot) Agreement Form:

Leaving the Practice: 

Releasing records FROM another office TO DuPage Pediatrics :

Authorization to Keep a Credit/Debit/HSA Card on File: :

Request to Set Up a Payment Plan:       

Authorization to have someone other than a parent or legal guardian bring in a child for care: :

HIPAA Notice of Privacy Practices:

  • Click here to view the HIPAA notice for DuPage Pediatrics.

Vaccine Policy Acknowledgement:

In order to view or print these forms, you will need Adobe Acrobat Reader installed. Click here to download it.

Contact Us

Send Us an Email

Our Location

1306 Plainfield Rd. Darien, IL 60561

Hours of Operation

Our Regular Schedule

* Evening Hours may vary


8:00 am-7:00 pm


8:00 am-7:00 pm


8:00 am-7:00 pm


8:00 am-7:00 pm


8:00 am-6:00 pm


9:00 am-12:00 pm