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

You mail email (by scanning or taking a photo with your phone) any forms to: Exchange@fourseasonspediatrics.com. You may 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.

Flu Vaccine Screening Form Link -Please complete prior to arrival

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: Registration Packet v2019

Well Visit Forms click link below:

• Please note that we are transitioning to the use of forms through CHADIS. Click here to We prefer you use these forms as they are very complete and improve care. Log into your web portal through a browser (not the Healow App). On the homepage, look for the Milestones Tile. If you are within 2 weeks of your well visit, you will see a button under Milestones called CHADIS. Click this button and it will show all questionnaires we want you to fill out. Please try to do at least one day before your appointment. Thank you.
• Well Physical Exam Forms – Only use these now if you do not have a web portal account

ADHD Forms click below:

• ADHD Forms — New Evaluation – click to do a new evaluation
• ADHD Follow up Appointments – we no longer post these forms. Please login to your Web Portal to see if your questionnaires have been posted, or call to request questionnaires if you are due and they are not on the portal.
• ADHD Coordinators have been trained to assist you with appointments. Your Coordinator will be able to assist you with:
  • Portal Login and finding the Questionnaires
  • Assigning Questionnaires if you do not have any in your portal
  • Ensuring that your questionnaires are completed BEFORE your appointment
  • Assisting with connectivity on the day of your appointment, found on the home page or click here.
• They are:
  • Michaela Capra: Dr. Elmer/Dr. Ungeheuer/Dr. O’Connor
  • Marcella Libby: Dr. Miller/Dr. Lange/Dr. Apruzzese

• Please note – we need questionnaires completed to properly evaluate, manage and recommend treatment. As of 3/27/23, if questionnaires are not filled out BEFORE your appointment, we will need to cancel your appointment. Log into your portal account through a browser (not available in the healow app). Please note we are now fully transitioned to the use of forms through CHADIS. These forms will be available through your web portal account by clicking here. Then click on “View Your Health Record” to login. If you forgot your password or user name click on “Trouble Logging In”. If you are within 2 weeks of your ADHD visit (OR you can request staff to assign ADHD questionnaires to schedule an appointment). When you login to your portal account, you will see a tile (square button) under Milestones called CHADIS. Click this and it will show all questionnaires we want you to fill out. Please fill these out as soon as possible to give the doctor more time to review them. Thank you.
• Once you have logged into your portal account and clicked CHADIS if there is a teacher questionnaire, click here to learn how to INVITE A TEACHER. It only has to be done once for a new teacher.
• Once you have logged into your portal account and clicked CHADIS if there is a patient or teen questionnaire, click here to learn how to INVITE YOUR TEEN to answer questionnaires. It only has to be done once

Consent and Record Release forms: You mail email (by scanning or taking a photo with your phone) any forms to: Exchange@fourseasonspediatrics.com or fax to the number listed above.

• Release for records going to our office (transferring in): Records release incoming v2018
• Release for records leaving our office (transferring out): Records release outgoing v2019
• Release for medical information to be emailed or faxed (to send individual items to other locations such as your school): PHI disclosure form
• 18 year old patient consent to speak to others (so we can talk to parents about the patient): 18 year old patient consent v2018

Updated information:

• Address change or update (please review closely): Address change v2018
• Insurance change or update (please review closely): Insurance change v2018

Other Forms:

• Pediatric History Questionnaire (required for each patient individually) History Questionnaire v2018
• Healthcare Parental Proxy form (for another adult to bring your child into the office for a visit, please read closely) Proxy Form v2018
• Race and Ethnicity form (Federally required to be asked to all patients) Race and Ethnicity Form v2018
• Office Policies and Consent for treatment (for review, please ask if you want your signed copy on file) Policies and consent form v2018

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