Form - Pure Pediatrics PC

Forms & Policies

Download and complete forms before your visit to save time.

Before your visit:

Please download, print, and complete forms ahead of time. Questions? Call

212-796-2196

New Patient Forms

New Patient Packet

Full 8-page packet - complete before your child's first visit

Record Release

Medical Record Release (Entering)

Request records from your previous provider

Medical Record Release (Leaving Practice)

Request your records to transfer to a new provider

Well Visit Forms

Demographics

Patient information form for well-child visits

Policies

Office Policies

Our practice guidelines and expectations for patients and families

Non-Discrimination Policy

Our commitment to equal, inclusive care for all patients

Terms & Conditions for SMS

Terms for receiving text messages from our practice

Privacy Policy

How we protect your personal health information

Need Help?

Our staff is happy to assist during office hours.