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**FREQUENTLY ASKED QUESTIONS**
NEW PATIENT APPLICATION
**Please fill in every required box before submitting the application
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Referred by- how did you hear about our practice?
Children's Name (s) - Please Enter All of Your Children's Names and Date(s) of Birth
Does your child/children have special needs? If any, please specify
Do you vaccinate on schedule? If not - please write your concern with immunizations and your preference
Name of Your Insurance - Please Specify if Your Insurance is Private, Child Health Plus or Medicaid
Please upload a copy of your chidren's insurance card/s. If you are filling this form out on your phone, you can take a picture of the insurance card/s and upload it from your photo library.
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Who was your last Pediatrician?
What are the dates of your children's last physical? (Your insurance may allow you 1 physical per year for children over 2 years old, please be aware of this before scheduling a physical exam)
Please give us 48 hours to process your application. If you don't hear back from us you can call us at 516-374-2228.
660 Central Avenue, Suite #3.
Cederhurst, New York 11516
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