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Name Change Form

To request that your name be changed with The American Board of Pediatrics, please fill out and submit this form along with the appropriate legal documentation (marriage certificate, divorce decree, court records, birth certificate, or current passport) supporting the change:

Open Form

Please submit your completed form with supporting documentation, allowing two weeks for processing. See the form for appropriate email addresses, physical address and/or fax numbers. If sending via fax, please download our fax cover letter