Four Seasons Pediatrics

Flash header display failed. Please install Flash and come back.

Forms

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)fourseasonspediatrics.com”  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

 

679 total views, 5 views today