Medical Release Form

If you are transferring care from another Doctor's office, we will need to request your child's medical records from that office. Please complete the following fields to the best of your ability.

I authorize you to send my child's health record to:

Robertson Pediatrics 150 N Robertson Blvd, Ste 307 Beverly Hills, CA, 90211 (Fax) 310-659-2420 (email) [email protected]

Redisclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. Refusal to sign/right to revoke: I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.

Patient Information

Newborn History

Please choose from the following options, if you are NOT the biological parent(s) of your child.

Medical History

If YES, then please list the medications and reactions to each medication below:

If Yes, please explain below:

If YES, then please list all dates and types of procedures below:

Please feel free to list any other concerns you might have regarding your child below:

Social History

If NO, please explain below:

If YES, then please list what type of pets are present in the household.

Family History


Please provide the names, sex, and DOB of all siblings.

Mother/ Primary Guardian

Father/Secondary Guardian

Emergency Contacts

Please list (2) emergency contacts that we can notify in the event that parents/guardians are not available.


Pleae note that we accept most major PPO plans (United, Cigna, Aetna, Blue Cross, Blue Shield).

Medical Consent Form for Child

If you anticipate that your child will be transported and supervised by individuals that are not the parents when visiting the office, then please complete the form below.

Please list the NAMES and RELATIONSHIP to patient for all authorized individuals below:

Telemedicine Consent Form

HIPAA Consent Form

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.


Our office requires that a credit card be kept on file for payment of any co-payment, co-insurance, deductible, or charge that may not be covered by your health insurance. This form will be kept confidential and only authorized staff has access to the information.

I acknowledge and authorize Sam Kim Physician Services, Inc to charge the above credit card account for any co-payment, co-insurance, deductible and/or charges not covered by my health insurance provider. I acknowledge that my card will be run in the event payment is not received within thirty days after I receive a statement. I agree to receive billing statements, invoices and receipts via the email I have provided to this office. If I am an uninsured patient I authorize payment at time of service. I agree to update any information regarding this credit card account.


Cancellation Policy