Electronic forms:

Click the link for the forms you need to complete forms electronically. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.

 

Considering Mendon Pediatrics or already planning to transfer? Click here.

Transferring to Mendon Pediatrics and need your records sent to us? Click here.

To complete all remaining forms and consents to get started at Mendon Pediatrics: Click here. 

Click the link for the forms you need to complete forms electronically. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.

 

Transferring TO Mendon Pediatrics? Click here.

Transferring FROM Mendon Pediatrics? Click here*

*Note: Your new medical provider may require their own medical records transfer form.

Still a Mendon Pediatrics patient, but would like us to send medical records for legal purposes, to your school, etc?  Click here.

 

If you have any questions regarding this process, please contact our Office Manager, Lisa Evans 585-624-4520.

Click the link for the form(s) you need. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service. 

Health History and Demographics

HIPAA- family

 

Over 18 years old?

Financial Policy and Privacy Practices

HIPAA 18

NYS Healthcare Proxy*

*This form must be printed and brought into the office

Consent to release private medical information is important when working with other Health Care professionals. Knowing and sharing information about a patient can help better diagnose and treat the situation.

Click the link for the form below. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.

Consent to release private medical information

Do you have a family member or childcare provider that will be bringing your child into the office for visits?

Click the link for the form below. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.

Family\Childcare Provider Authorization to Consent to Treat

Click the link for the forms you need. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service. 

 

MCHAT screening form

Lead screening form

 

Team up visit forms

Healthy Habits Ages 2-9

Healthy Habits Ages 10-18

Asthma visit

Asthma Control Test: Ages 4-11 years

Asthma Control Test: Ages 12 yrs and older

ADHD visit:

Ages 15 and older

Depression\Anxiety visit:

Under 10 years old

Ages 10-12

Ages 13 and up

 

Postnatal screen:

EPDS Postnatal form

 

Vanderbilt- Parent forms

NICHQ Vanderbilt Assessment Scale - Parent Form

NICHQ Vanderbilt Assessment Scale - Parent Follow Up Form

Vanderbilt- Teacher forms

NICHQ Vanderbilt Assessment Scale - Teacher Form

NICHQ Vanderbilt Assessment Scale - Teacher Follow Up Form