Medical Form

Dear Physician, my child is enrolled in The Cottage Garden, a family day care program that is licensed by the Massachusetts Department of Early Education and Care. The Department of Early Education and Care regulations require that this Medical History form be completed and signed by the enrolled child’s physician or source of health care. Additionally, evidence that the child has been successfully immunized in accordance with the Department of Public health’s recommended schedules must be submitted and signed by the child’s physician or source of health care.

Please supply a WRITTEN NOTE from your health care provider, for The Cottage Garden records, if your child:

  • Has any allergies? For ex. Can’t have cow’s milk but can have soy-please be specific.

  • Takes any prescribed medication?

  • Takes any Homeopathic Remedies?

  • Needs to have an EPI Pen on site

Please also send a copy of your child’s Health Record and Immunizations or letter of exemption based on your religious beliefs.

Evidence of a physical examination and a LEAD test is valid for one year from the date the child was examined and shall be renewed annually thereafter.