Forms

Patient Forms

Below is a list of downloadable PDF forms. Feel free to fill out any of the forms before your appointment.

Child Patient Health Information Authorization Form

Meet The Doctor Interview Form

Motor Vehicle No-Fault Law Form

Ages & Stages Questionnaire for 2 ½ year well visit

Telemedicine Forms

Please complete the forms electronically and email them to us via your patient portal

Edinburgh Postnatal Depression Scale

Vanderbilt Parent Rating Scale

Have a Question?

Phone: (585) 223-6111
Fax: (585) 223-0878

We're Accepting New Patients!

Our pediatric office is accepting new patients. Located in Fairport, NY, we care for patients across Monroe, Wayne, and Ontario Counties!

Physical Exams

School, Sport, & Camp Forms

New York State mandates physical examinations for students entering the following grades. Sports, summer camps, and other activities usually require annual physicals. We will complete a physical form for you at the time of your child’s annual physical exam and ask that you keep a copy for your future needs.

Forms

Patient Forms

Child Patient Health Information Authorization Form

Meet The Doctor Interview Form

Financial Policy Form

OMT Consent Form

Motor Vehicle Accident Form

Motor Vehicle No-Fault Law Form

Newborn Information Form

New Patient Form

Patient Update Form

New Patient Transfer In Form

Prenatal Interview Form

Ages & Stages Questionnaire for 2 ½ year well visit

PHQ-9 and GAD-7 Forms

SCARED Parent Form

SCARED Child Form

Telemedicine Forms

ADHD Rating Scale Adult

CES D Kids

Edinburgh Postnatal Depression Scale

GAD7 Questionnaire

M-CHAT

PHQ-9 Modified Teens

PHQ-9 Adult

Vanderbilt Parent Rating Scale

Have a Question?

We're Accepting New Patients!

Physical Exams

School, Sport, & Camp Forms

Visit Our New Patient Center

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