If you are a new patient, please fill out this form to help us get to know you and your child's medical history.

Welcome

Transfering to Mendon Pediatrics

Consent to Release Private Health Information

New Privacy Practice Forms 10-11

Privacy Practice Signature Form  - Please sign after reading the new privacy practice form 10-11.

Financial Responsibility Statement Form

HIPAA Family Authorization

Family Demographics Information Form

Records Transfer Request Form. Please download, fill out and drop off/ fax to our office to transfer your records. If you have any questions regarding this process, please contact our Office Manager, Lisa Evans 585-624-4520.

Records Transfer Requests

Filling out the appropriate HIPAA forms before your appointment can be time-saving and convenient for you. Especially if you have a little one to console.

HIPAA Family

18 year old HIPAA

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.

Consent to Release Private Health Information

NICHQ Vanderbilt Assessment Scale - Parent Form

NICHQ Vanderbilt Assessment Scale - Teacher Form

NICHQ Vanderbilt Assessment Scale - Parent Follow Up Form

NICHQ Vanderbilt Assessment Scale - Teacher Follow Up Form