Request an Appointment
Please do not use this form if you have an urgent medical problem or you need to reschedule an existing appointment. Instead, contact our office at (914) 761-1717. After you submit your request, our appointment scheduler will respond within 48 hours. See below for forms to complete. Established patients may log in to the patient portal to request appointments and update forms.
Patient Registration Forms
Westchester Park Pediatrics in Purchase, New York, welcomes you to our practice. Once you have made your initial appointment, you may preregister online by completing the interactive form(s) below, or you may download and print the form(s), fill them out, and bring them with you to your first visit. Completing the forms prior to your visit will help speed up the new patient registration process.
Also, be sure to bring any diagnostic films or other test results that may have been ordered or performed by another physician.
- Patient Registration
- New Patient History
- Office Policy
- Authorization for Release of Health Information Pursuant to HIPAA
- Medical Record Request
- Minor Consent- Spanish
- Minor Consent- English
- Vanderbilt ADHD Diagnostic Teacher Rating Scale
- Vanderbilt ADHD Diagnostic Parent Rating Scale
- NICHQ Vanderbilt Assessment Follow-up - Parent informant
- NICHQ Vanderbilt Assessment Follow-up- Teacher informant
Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.