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 TO Bass River Pediatrics to Another Facility
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.
Medical Record Transfer FROM Bass River Pediatrics to Another Facility
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.
18 & Over Medical Information Release Form
This form is to be filled out by PATIENTS 18+ ONLY - Permission to disclose Medical Information Form
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.
These forms are available to download for distribution to parents and teachers when requested.
COVID 19 Laboratory Required Reporting CARES ACT Section 18115