Patient Forms
Established Patients Access
Through our patient portal, you can request appointments, request medication refills, and print forms. Your request will be responded to within 24-48 hours, during normal business hours. If you do not receive confirmation of your request within 48 hours, please contact our office by phone.
- Patient Portal Appointment Request
- Patient Portal Medication Request
New Patient Information
Adolescent Transfer Policy
Please note for adolescents that are looking to transfer to our practice and are 14-years-old or older that Delaware Pediatrics only accepts the adolescent as a transfer if the adolescent has a sibling (s) under the age of 14-years-old, who also need to transfer. If you have any questions or require further information about our transfer policy, please call our office at (716) 884-0230.
Forms Information
To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com.
We recommend printing and filling out the forms below before your first appointment with our office. Please print and complete the Authorization of Release (Transfer in/Transfer out) form and return it to your previous doctor’s office. We do not request medical records on your behalf. It is your responsibility to ensure your child’s records are transferred to our office in a timely manner. If your records are not received prior to your scheduled NEW patient appointment, your appointment maybe rescheduled.
- New Patient Welcome Letter
- Adolescent Letter
- New Patient Demographics
- Comprehensive Health Assessment Age (0-17)
- Comprehensive Health Assessment Form Age (18 to 21)
- Over 18 HIPAA
- Vaccine Policy Statement
- Patient Responsibility Agreement
- Notice Of Privacy Practices
- Authorization To Fax
- Patient-Centered Medical Home
- Well Child Exam & Telehealth Financial Policy
- Transfer In Form
- Transfer Out Form
- ADHD Care Assessment
- ADHD Management Protocol
- Authorization for Medical Treatment of Minors
- Adult Primary Care