Thank you for choosing Tenafly Pediatrics as your pediatric health provider.
Simply download and fill out the appropriate form(s) and hand deliver them to your primary office location.
Note: These are PDF files, you may need to download Adobe Acrobat Reader to view them.
Federal law prevents us from sharing information with you about your child age 18 or older without their permission. Please have them sign this form when they turn 18 to grant us permission to keep sharing their information with you.
If you would like the flu vaccine for yourself when you bring your child in for theirs, then please print and complete this form before you come in. **Please note that the flu vaccine for parents is self-pay only, it will not be filed with insurance.
Some quick guidelines…
Note: We can email back the completed form securely with a program called ShareFile. It is a program that encrypts the email to meet the security standards (HIPAA) that the government requires. In order to receive these emails you will need to confirm your name and email address. Thank you!