Clinical Forms

The Clinical Forms page contains documents that are useful to community providers in coordinating care of their patients at Seattle Children's.

These forms must be printed out, completed, and faxed to their designated destinations.

Direct Admit Packet

This packet includes the criteria, instructions and forms required for direct admission to Seattle Children's when the primary care physician or a member of the practice will be the attending physician.

• Admission History and Physical form (PDF)
• Criteria and instructions for direct admission (PDF)
• Direct Admit Worksheet and Guidelines for Children's Providers (D.A.W.G.) (PDF)
• Direct Admit Worksheet and Guidelines for Community Attendings (D.A.W.G.) (PDF)
• Instructions for families (PDF)

History and Physical Exam - Inpatient Admission

The Inpatient Admission form (PDF) is completed by the primary physician or the physician admitting a patient to Seattle Children's.

All sections of the form should be completed. The form should be faxed to the Emergency Department at 206-987-3945 if the patient is being directed there. The form also should be brought with the patient to the hospital.

If the patient will be admitted directly to the floor, the patient should bring the form as part of the direct admit packet.

Surgical Admit / Day Surgery H-and-P

The Surgical Admit / Day Surgery H&P form (PDF) is completed by the primary physician or the physician completing the pre-operative H&P.

All sections of the form should be completed, and the form is faxed to Admitting at 206-987-5018.

Pediatric HIV Consent and Counseling Checklist

Pediatric HIV Consent and Counseling Checklist (PDF)

Radiology Exam Request Form

The Radiology Exam Request form (PDF) is used for requesting all procedures done at Children's Radiology Department.

Please fax a copy to 206-987-2730 and send the original with the patient.