Office Forms
Before your appointment, please print and fill out any of the necessary forms below.
If you have questions about how to obtain records from or send records to another provider, please call our office at 585-244-9720.
To view the forms listed below, you will need Adobe Reader.
Administrative and New Patient Forms:
- Release of Record Form
- Notice of Privacy Practices
- Adult Patient Authorization
- Release of Records from Former Pediatrician
- Demographic Form
- Permission Regarding Communication (HIPAA) Form
- Family Medical History Form
- Adult-Patient Authorization (for patients 18 years & older)
- Release of Records Form
- Release of Records From Former Pediatrician
ADD/ADHD Forms & Questionnaires:
- ADHD Questionnaire – for Parent to Complete
- Vanderbilt Assessment – Parent Form
- Vanderbilt Assessment – Teacher Form
- Adult ADHD Self-Report Scale – Patient Form
- Vanderbilt Assessment – FOLLOW-UP – Parent Form
- Vanderbilt Assessment – FOLLOW-UP – Teacher Form
