Forms

All of our forms are Adobe PDF documents. Once you download the necessary forms to your computer, you may type directly into them and save them on your computer as you are working. To return any forms by email, please send them as email attachments. You may also print the forms and write on them if you prefer. To access these forms you will need to have the free Adobe Reader installed on your computer. Most computers already have the Adobe Reader installed, but if you need to install it please click this button:

To ensure the data you enter in the PDF documents displays and saves correctly, please do not use Preview on a Mac, or any PDF browser plug-ins. Download the PDF files to your computer and only open them with Adobe's PDF reader.

If you would prefer any of our forms be sent to you by mail or by e-mail, please contact our reception by phone at 650-595-5437 or by email at info@wholechildwellness.com.

New patient forms

Thank you for your interest in becoming a patient at Whole Child Wellness.

Before scheduling your first appointment, we ask that you take the time to review, fill out, and return the documents and forms as outlined below. A new patient appointment will only be scheduled after we receive your completed forms. Once we receive your completed forms, our reception will call you to schedule your appointment.

The information that you provide will greatly enhance and maximize the time you spend with your doctor or nutrition consultant on your first visit, so please fill out the questionnaires as accurately and thoroughly as possible. For consultations regarding specific health issues, we also ask that you send all previous medical records, including previous lab work and consultations with other healthcare specialists, to our office at least three days before your scheduled visit. This will ensure that your doctor can provide you with the best comprehensive care. An “Authorization to Release Medical Information” form is included below that you can use to request medical records from your other healthcare providers.

Please consult the lists below for the type of appointment you are requesting (well-care, consultation for a specific health concern, or nutritional consultation) to ensure you fill out the correct forms.

For new WELL-CARE appointments with one of our pediatricians, please complete the following:

For new CONSULTATION appointments for specific health concerns with one of our pediatricians, please complete the following:

For new NUTRITION CONSULTATION appointments with Kandice Stellmon, please complete the following:

You may return the forms by email (as email attachments) to info@wholechildwellness.com, by fax to 650-595-5438, or by regular mail to our office address at:
Whole Child Wellness
1601 El Camino Real, Suite 101
Belmont, CA 94002

Other forms

Authorization to Release Medical Information to Whole Child Wellness - Use this form to request medical information be sent to Whole Child Wellness from another practitioner.

Authorization to Release Medical Information from Whole Child Wellness - Use this form to request medical information be sent from Whole Child Wellness to another practitioner. A record copy fee may apply as detailed in the Whole Child Wellness Policies document.