Children enrolling in Montana licensed child care need a medical professional's statement about their health. This short form, often called the pink form, records known conditions, specific allergies, special medication, whether immunizations are current and any restrictions, then the professional certifies the child poses no unusual health risks to themselves or other children in day care.
A medical professional, such as a physician, physician assistant or APRN, completes the examination fields and signs the statement with their printed name and date. The parent's name appears at the top with the child's details.
Download the current version from the source each time; forms change without notice.
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. Montana child care licensing posts a Spanish version, Declaración de Salud Pediátrica, alongside the English form, so a family can bring the version they read to the medical visit.
No. It has a single line asking whether immunizations are current. The vaccine dates themselves are documented in a companion record, such as Montana's Certificate of Immunization (HES-101), which the family provides to the child care program separately.
The professional writes in the child's name and certifies they have examined the child and find no unusual health risks to the child or to other children in the day care setting, then prints their name, signs and dates the form.