This is the only form you need — your other forms are already on file. It confirms that Dr. Hojin Lee will continue your child's care and that Grove Pediatrics' current office policies apply going forward.
Patient info (up to 4 children), guardian contact info, emergency contacts, pharmacy, and insurance details.
Birth history, past medical history, allergies, medications, and family health history.
Consent to treat, financial responsibility, and acknowledgment of appointment/no-show/vaccine policies.
Confirms you've received our Notice of Privacy Practices describing how your child's health information is used.
How your child's health information may be used and disclosed, and your privacy rights.
Authorize Grove Pediatrics to release or obtain records to/from another party.
For new patients: authorize your previous pediatrician to send records to us.
For patients transferring away: authorize us to send records to their new practice.
Complete this history form ahead of your child's sports physical; Dr. Lee completes the exam and clearance at the visit.
The official Commonwealth of Virginia form (MCH 213G) — Dr. Lee completes and signs Parts II & III during your visit.
The official BSA Annual Health and Medical Record — bring Parts A & B completed, and we'll complete Part C at your visit.
Authorize school, camp, or childcare staff to administer a medication to your child.
Authorization and emergency action plan for known severe allergy (anaphylaxis).
Authorization and asthma action plan for a rescue inhaler at school or camp.
Prefer to fill these out in person? Just arrive 10–15 minutes early to your first appointment and our front desk team will help you.