Palouse Pediatrics

Palouse Pediatrics, Pullman
1205 S.E. Professional Mall Blvd. Suite 104
Pullman, WA 99163 (map)
Phone: 509-332-2605
Fax: 509-334-5754

Palouse Pediatrics, Moscow
1420 S. Blaine St, Suite 5
Moscow, Idaho 83843 (map)
(Located in Eastside Market Place)
Phone: 208-882-2247
Fax: 208-882-2292

Mutual Exchange of Information Form

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Fill-out the form below and then print it out. Your information will not be saved or sent.

In order to provide complete services for your child, __________________________________________, we may need pertinent information from other individuals or agencies working with your family. We may also need to share information with others so that they can provide better services. Please check the agencies or persons listed below from whom we may receive and to who we may give information if it is necessary. Please include names of doctors when appropriate. We will need your signature for both sections.
To release information to:
Family Doctor Name
Mental Health Clinic
Specialist’s Name
School District
Other
Patient or legally authorized individual signature
Date
Printed name if signed on behalf of the patient
Date
To obtain information from:
Family Doctor Name:
Mental Health Clinic:
Specialist’s Name:
School District:
Other:
Patient or legally authorized individual signature:
Date:
Printed name if signed on behalf of the patient:
Date: