Forms

Printable Office Forms

Prior to your appointment, the forms listed below can be printed for your convenience. Filling them out beforehand will save you time by not having to complete them during your appointment. If you elect not to fill out these forms ahead of time, please arrive 15 minutes prior to your scheduled time. (You may download Adobe Reader for free at www.adobe.com.)

  • Authorization for Release of Medical Records

    Below, is our Authorization for Release of Medical Records form. If you have already consulted with us regarding becoming a new patient at our practice and was directed to do so, please complete this as soon as possible. This is an imperative step in becoming an established patient , as the records from your child's previous pediatrician is cruical to determine what appointment is deeemd necessary to schedule. 


    If you are interested in becoming a new patient at our practice, please give the office a call at (516) 771-8123 prior to filling out any required documents to make sure that we are the best fit for your child! 

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  • Behavioral Health Forms
  • Early Intervention Form

    Below, is our Early Intervention form. If you were directed to do so, please complete this prior to your next appointment. 


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  • Healthix Form

    Below, is the Healthix form. If you are a new patient and was told to complete the New Patient Registration form, please complete this form as well. 


    If you are looking to become a new addition to our practice, please give the office a call at (516) 771-8123!

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  • HIPPA Form

    Below is our HIPPA form. If you were directed to do so, please complete this form prior to your appointment at our office! 


    If you are looking to become a new patient at our practice, please give our office a call at (516) 771-8123!

    Download PDF
  • New Patient Registration

    Below is our New Patient Registration Packet. If directed to do so, please download the forms and complete them before coming in for your first appointment! 


    If you are interested in becoming a new patient here at Long Island Pediatrics, please give the office a phone call at (516) 771-8123!

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  • WIC Referral Form

    Below is the WIC Referral Form. If you were directed to complete this, please fill this out to the best of your knowledge prior to your appointment. 

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  • Credit Card on File Authorization Form

    Below, is our credit card on file authorization form. If directed to do so, please complete this prior to your next visit. 


    * Please refrain from placing AMEX as the credit card on file as we do not accept AMEX*

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