Pediatrics Forms

New Patient Registration Forms

To save time at your visit you can download this form, complete, and send back into us via fax 215-525-8670 or email pediatrics@fight.org. We’ll review the forms for accuracy when you come in and ask you to sign them in-person.

Download Form (PDF)

Behavioral Health Screening Forms

Vanderbilt – This is a tool that is used to screen for ADHD whenever there are behavioral concerns. There is a version for parents and another version for teachers.

SWYC – This screens for your child’s developmental abilities and behaviors, as well as the well-being of the parents.

PSC Y and PSC – We use this tool to screen for behavior problems in children and adolescents beginning at age 6.

SCARED – This is a tool that we use to screen for anxiety in children and adolescents.

PHQ-9 – We use this questionnaire to screen for depression in children and adolescents.

School and Daycare Forms

Philadelphia School District Physical Form – This form is required annually for all children entering the Philadelphia School District.

Daycare form – This form is required for children entering child care (such as daycare, preschool and Pre-K).

School med administration forms – Some patients may need the school nurse to administer a child’s medication while at school (e.g. a child which asthma who needs albuterol). In these cases this form must be completed by a medical provider.

PIAA – This is the form that the Philadelphia school district requires for all youth who are participating in sports. Be sure you complete sections 3, 4 and 5 BEFORE asking us to complete section 6.

Other

Driver’s learner’s permit application – All applications to obtain a learner’s permit from PENNDOT require the medical provider to complete a part of this form.

Program Information

  • Location: 1207 Chestnut Street, Philadelphia, PA 19107 - 5th Floor

  • Phone: 215-525-8600. Fax: 215-567-1012

  • Contact: Dr. Mario Cruz

  • Email: pediatrics@fight.org

  • Hours: Monday & Wednesday: 9am-6pm - Tuesday, Thursday, Friday: 9am-5pm

Spotlight On

Karam Mounzer, MD

Dr. Mounzer identified two major gaps in the care of patients with HIV/hepatitis C (HCV) co-infection, and the complexity of multidrug-resistant HIV treatment. He is involved with many clinical trials focusing on drug development and better understanding of HIV immunopathogenesis with the Wistar Institute. He is involved in teaching and mentoring fellows, residents and students.

Learn More about Spotlight On
Dr. Karam Mounzer

Dr. Mario Cruz

Dr. Cruz is a board certified pediatrician who joins Philadelphia FIGHT as the Medical Director for our Pediatrics and Adolescent Health Center. He completed his undergraduate training in Biology and Psychology from Union College, his medical school training at Albany Medical College, his residency training at St. Christopher’s Hospital for Children, and his Chief Residency at the Albert Einstein Medical Center


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