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:
- Demographic Form
- Permission Regarding Communication (HIPAA) Form
- Adult-Patient Authorization (for patients 18 years & older)
- Family Medical History Form
- Release of Records Form
- Release of Records From Former Pediatrician
- NY State COVID Vaccine Form
Well Visit Questionnaires:
- ASQ – 9 Month Questionnaire
- ASQ – 18 Month Questionnaire
- ASQ – 30 Month Questionnaire
- M-CHAT – for 18 month and 2 year visits
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
Mental Health Forms:
- Confidential Family Mental Health Survey
- Patient Health Questionnaire (PHQ.9)
- Screen for Child Anxiety Related Disorders (SCARED) – PARENT FORM
- Screen for Child Anxiety Related Disorders (SCARED) – PATIENT FORM
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COVID-19 Vaccine Forms
- COVID-19 Pre-Vaccination Screening Form
- Please print & bring completed form to your COVID vaccine appointment
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