Tenafly Pediatrics

Patient Forms

For your convenience, please see the patient forms available for download below...

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. 

This is very helpful to complete prior
to coming in the first time

This must be signed by all new AND existing patients 

Complete this form if you are transferring to us from another pediatric practice

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.

Provided by the National Institute for Children’s Health Quality.
Used for diagnosing ADHD

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.

Do you have a form that needs to be completed by the doctor/staff?
You can email it to your primary office directly!

Some quick guidelines…

  • You must complete your part of the form prior to emailing it to us. Whether it’s the patient’s name, date of birth, or some medical history, it must be completed first.
  • Please send the form as an attachment, rather than just embodied in the email. If sending a picture of a form, it must be very clear and sent as an attachment.
  • Please allow 2 business days for a form to be completed.
  • Only use the email addresses below for forms, not for appointment requests. 

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!