508.394.2116
(For emergency, dial 911)

Online and Downloadable Forms

Below is a list of forms and documentation available to you on the Bass River Pediatrics web site.

Change of Information Form
An online portal where you can change your current information on file with us.

Medical Record Transfer Form - To or From BRPA (pdf)
Authorization for Bass River Pediatrics to transfer records to another practice. This is a printable form. You must print it, fill it out and sign it. Then you can either scan/email it to us, snail mail it, or bring it in.

PFIZER COVID VACCINE INFO SHEET FOR 6mos to 4 years

This form is required reading for anyone receiving the Pfizer Covid 19 Vaccine for children ages 6mos to 4 years.

PFIZER COVID VACCINE INFO SHEET FOR RECIPIENTS AND CAREGIVERS

This form is required reading for anyone receiving the Pfizer Covid 19 Vaccine for children ages 5 to 11.

Vanderbilt Forms - Parent

These forms are available to download for distribution to parents and teachers when requested.

Vanderbilt Forms - Teacher

COVID 19 Laboratory Required Reporting CARES ACT Section 18115

18+ MEDICAL RELEASE INFORMATION

This form is required to be signed for any patient 18+ to allow parents/caregivers/guardians access to Records and appointments.