Office Policies and Insurance Forms  

Please complete and submit each of the following documents to our office staff prior to or at the time of your first visit.  Please fill out separate forms for each child in your family.
1.  Office and Financial policy
2.  Registration
3.  Transfer of Records
4.  Privacy Statement
5. Health History form
6. Food Diary
Note: This form is to be filled out and faxed back to the office 1 week in advance of a visit with the dietician.
   

Peconic Pediatirics is a division of Allied Pediatrics of New York, PLLC
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