Welcome to Bloomington Pediatrics


Release of Information Forms

Medical Records Release Form

Complete this form if you are transferring your medical records

Consent to Treat an Unaccompanied Minor

Complete this consent form for your child aged 16-17 who wishes to attend their appointment alone.

Under 18 Release of Information

Choose this option for the parent or legal guardian to consent to another family member or adult to have access to your under age 18 child's patient information

Age 18 and Up Release of Information

Patients over the age of 18 must complete this release to allow a parent, legal guardian or other adult to have access to their patient information