(203) 245-0496

Before Your First Visit

Before Your First Visit

New Patient Forms

Please print and fill out the following two forms prior to your first visit

Patient Visit Checklist

In order to provide the most efficient and comprehensive care to your child, please ensure you have the following items for all of your child’s appointments:

  • NEW PATIENTS – the Intake Form above
  • Your child’s health insurance card
  • Any necessary referral/authorization number from your Primary Care Physician if required by your insurance plan (please double-check with your particular plan – this must be obtained prior to the visit)
  • Any changes to insurance, address, pharmacy, or pediatrician
  • All pertinent original x-rays/ CT scans/ imaging scans (not just the report)
  • Results from any applicable diagnostic tests (hearing test, sleep studies, etc)
  • Co-payment (cash, check or Mastercard/Visa credit cards)

Cancellations- please notify us as soon as possible if you need to cancel or change your scheduled appointment. A $50 No Show Charge will be applied to your account if you do not notify us of a cancellation 24 hours prior to the appointment.