GoKids Boston

Empowering Kids to Grow Up Healthy

Clinician Referral Form

Are you a clinician or health professional interested in referring a patient to GoKids? If so, please complete the information below and we will contact the parent/guardian to initiate enrollment at GoKids.

PATIENT NAME

PARENT/GUARDIAN NAME

REFERRING CLINICIAN NAME

By checking this box below I give permission for my patient to participate in moderate-to-vigorous aerobic and strength-type physical exercise, with or without restriction.