Online Forms
Easily Locate the Forms You Need
Quickly and conveniently access the patient forms you will need before your appointment. Forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.
Please call our office if you have questions or need assistance filling out the forms at 585-624-4520.
Annual Forms
Click the link for the form(s) you need. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.
Consent to Release Information
For current patients only:
(Please do not fill out these forms if you are transferring to our office. You will need to contact your current physician's office and complete their transfer records form).
Consent to release private medical information is important when working with other Health Care professionals. Knowing and sharing information about a patient can help better diagnose and treat the situation.
*The provider releasing the records may require their own release form.
** If confidential information is in the medical record, the patient will also need to complete this form.
(Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.)
Form Request
Click the link for the forms you need. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.
Medication Refill Request
Click the link for the form(s) you need. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.
Medical Records Transfer
Click the link for the forms you need to complete forms electronically. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.
Transferring FROM Mendon Pediatrics to another practice?
If you have any questions regarding this process, please contact our Office Manager, Lisa Evans 585-624-4520.
New Patients
Electronic forms:
Click the link for the forms you need to complete forms electronically. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.
Are you EXPECTING your first baby and want to meet one of our providers OR are ready to establish care at Mendon Pediatrics? CLICK HERE.
Has your first baby been born or are you transferring care to Mendon Pediatrics? CLICK HERE to complete our new patient forms.
NYS Healthcare Proxy
Screening Forms
Click the link for the forms you need. Completed forms are submitted directly to Mendon Pediatrics via a fully HIPAA compliant service.
18 Month and 2 year WCC
3-6 year WCC
Asthma visit
ADHD visit
Depression\Anxiety visit:
1\2\4\6\15 month WCC:
Vanderbilt- Parent forms
- NICHQ Vanderbilt Assessment Scale - Parent Form
- NICHQ Vanderbilt Assessment Scale - Parent Follow Up Form
Vanderbilt- Teacher forms
Shared Custody/Divorce
In the event of separation\divorce, legal documentation of custody must be on file at Mendon Pediatrics.
If there is a joint custody agreement in place, BOTH parents\legal guardians must authorize any other parties to authorize Medical care and to receive access to the patient's medical record.
CLICK HERE to complete the required authorization form. NOTE: each parent must complete their own form.