Four Seasons Pediatrics

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To save time at your visit, we strongly encourage all patients to print and bring their filled out forms to the appointment.  You may:

  • email the form to our staff or to “bkoehler(at)”  You will need to replace (at) with @ when emailing.
  • fax the form to us at 518-383-3255 if that works best.

Please note that all forms that require a signature must be hand signed, we will not accept a typed or digital signature.

Registration Forms (this includes most of the items below, so you can print the entire set at one time)

  • Complete Registration Packet (New Patient Paperwork) – click this link: 2018 Complete

Well Visit Forms click link below:

ADHD Forms click below:

Consent and Record Release forms:

Updated information:

Other Forms:

  • HIXNY (Health Information Exchange of New York) consent (to exchange records with Urgentcare or ER)2018 HIXNY
  • Pediatric History Questionnaire (required for each patient individually)2018 PHQ
  • Healthcare Parental Proxy form (for another adult to bring your child into the office for a visit, please read closely)2018 proxy
  • Race and Ethnicity form (Federally required to be asked to all patients)2018 r and e form
  • Office Policies and Consent for treatment (just for review, please ask if you want your signed copy on file)2018 policies and consent


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