Office Forms

IMPORTANT

Please scroll BELOW the “FORMS” section to FIND YOUR CHILD’s AGE CATEGORY to print off the required select forms in advance of your appointment to save time. Along with your completed forms, please bring your insurance card with you.

Adolescent Confidentiality Statement Authorization to Accompany Child Cancellation/No Show Policy Change of Address Change of Insurance COVID Patient Advisory & Acknowledgment: Routine Care COVID Patient Advisory & Acknowledgment: Urgent Care Guarantor Agreement Non-Covered Services Agreement Nondiscrimination Notice Notice of Privacy Practices NYSIIS Patient Information Patient Information Form Release of Records Form Telemedicine Consent Form

Declaración de confidencialidad del adolescente Autorización para Acompañar al Niño Política de cancelación / no presentación Cambio de dirección Cambio de seguro Acuerdo de garante Acuerdo de servicios no cubiertos Aviso de no discriminación Aviso de prácticas de privacidad Información del paciente de NYSIIS Información del paciente Liberación de registros

New & Transferring Patients

Records Release Form

Newborns

Newborn 1st Visit Forms

Babies 1 Month to 2 Years

Young Children ages 3-9

3 Year Well

Developmental Screening Personal Social Copay, Coins, Ded, Non-covered Services Consent Form

4-5 Year Well

Developmental Screening Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

6 Year Well

Developmental Screening Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

7 Year Well

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

8 Year Well

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

9 Year Well

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

Early Adolescent

10 Year Well - Male

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

10 Year Well - Female

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

11 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

11 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

12 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

12 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

Middle Adolescent

13 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

13 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

14 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

14 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

15 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

15 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

Late Adolescent

16 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

16 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

17 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

17 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

18 Year Well - Male

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release Copay, Coins, Ded, Non-covered Services Consent Form

18 Year Well - Female

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release Copay, Coins, Ded, Non-covered Services Consent Form

19 Year Well - Male

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

19 Year Well - Female

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

20 Year Well - Male

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

20 Year Well - Female

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

21 Year Well - Male

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

21 Year Well - Female

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

For more Information regarding Vaccine Information, please visit the following website at:

AAP Immunizations Page CDC Vaccine Information Sheets

As we follow the guidelines established by the American Academy of Pediatrics , please visit the following links for more information:

AAP Pediatric Patient Education AAP Bright Futures Resources for Families Healthy Children.org

office forms

***IMPORTANT***

New & Transferring Patients

Newborns

Babies 1 Month to 2 Years

2 Week — 1 Month Well

2 Month Well

4 Month Well

6 Month Well

9 Month Well

12 Month Well

15 Month Well

18 Month Well

2 Year Well

Young Children ages 3-9

3 Year Well

4-5 Year Well

6 Year Well

7 Year Well

8 Year Well

9 Year Well

Early Adolescent

10 Year Well - Male

10 Year Well - Female

11 Year Well - Male

11 Year Well - Female

12 Year Well - Male

12 Year Well - Female

Middle Adolescent

13 Year Well - Male

13 Year Well - Female

14 Year Well - Male

14 Year Well - Female

15 Year Well - Male

15 Year Well - Female

Late Adolescent

16 Year Well - Male

16 Year Well - Female

17 Year Well - Male

17 Year Well - Female

18 Year Well - Male

18 Year Well - Female

19 Year Well - Male

19 Year Well - Female

20 Year Well - Male

20 Year Well - Female

21 Year Well - Male

21 Year Well - Female

For more Information regarding Vaccine Information, please visit the following website at:

As we follow the guidelines established by the American Academy of Pediatrics , please visit the following links for more information:

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Schedule a visit

PLEASE CALL THE OFFICE TO MAKE YOUR APPOINTMENT

631.509.0671

IMPORTANT