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 for patients UNDER the age of 18*

Click here for patients OVER the age of 18*

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

 

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

 

Over 18 years old?

HIPAA 18

NYS Healthcare Proxy*

*This form must be printed and completed

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 medical records- Mendon Pediatrics TO another provider

 

Consent to release medical records- Another provider TO Mendon Pediatrics**

**The provider releasing the records may require their own release form

 

Consent to release Protected health information\medical records- this form must be completed by the patient.

 

Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.

 

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. 

18 Month and 2 year WCC

MCHAT screening form

3-6 year WCC

Lead screening form

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

 

1\2\4\6\15 month WCC:

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

In the event of separation\divorce, legal documentation of custody must be on file at Mendon Pediatrics.

If there is a joint custody agreement in place, BOTH parents\legal guardians must authorize any other parties to authorize Medical care and to receive access to the patient's medical record.

Click here to complete the required authorization form. NOTE: each parent must complete their own form.