• CNY FAMILY CARE PEDIATRIC PATIENT INTAKE FORM

    Welcome to CNY Family Care! We are pleased to serve your health care needs and those of your family. To assist our providers and staff, please complete this information to the best of your ability
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  • PARENT #1 INFORMATION

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  • PARENT #2 INFORMATION

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  • Appointment Reminder via Text message or Phone call

    Please be aware, CNY Family Care can only send appointment reminders to one designated number. Our preferred method is text which requires a cell phone. Please indicate below the specific number you would like us to send appointment reminders to.

  • HIPAA CONTACT INFORMATION

  • LEGAL GUARDIAN INFORMATION

  • PRIMARY INSURANCE INFORMATION

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  • SECONDARY INSURANCE INFORMATION

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  • The above information is accurate to the best of my knowledge.

    I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled, to CNY Family Care, LLP. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health / medical plan to issue payments directly to CNY Family Care, LLP for medical services rendered to myself and / or my dependents. I understand that I am personally financially responsible for any amounts not covered by insurance. This assignment shall remain in place until I revoke it.

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  • Immunization History

    IMPORTANT: We ask that you attach a copy of your child’s immunization record and return itwith this intake form.

  • ALLERGIES

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  • MEDICATIONS

  • CHILDHOOD ILLNESS

  • SERIOUS ACCIDENTS OR INJURIES

  • MEDICAL PROBLEMS REVIEW

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  • Child’s Former Primary Care Provider

  • HOSPITALIZATIONS

  • ASSISTIVE DEVICES

    Please indicate if the child currently requires any assistive devices.

  • OBSTETRICS/ GYNECOLOGIC HISTORY

    (For girls only)

  • BIRTH HISTORY

  • FAMILY HISTORY MEDICAL ISSUES

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  • HOME ENVIRONMENT

  • BARRIERS TO CARE

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  • Personal Habits

  • I have completed this Pediatric Intake Form to the best of my ability

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  • Well Visit Schedule for Pediatrics and Adolescents

    CNY Family Care LLP
  •  Age  Reason for Visit  Immunization  Exam  Lab  Other
    3-5 Days Old (24-48
    hours after hospital
    discharge)    		 Weight & Jaundice Check   Recombivax (Hep B), Beyfortus (RSV)-if
    needed    		      
     2 Months  Growth & Development
    Check    		 Vaxelis(Dtap,Hib,Polio,Hep B), Prevnar20
    (Pneumococcal), RotaTeq(Rotavirus)    		      
     4 Months  Growth & Development
    Check    		 Vaxelis(Dtap,Hib,Polio,Hep B), Prevnar20
    (Pneumococcal), RotaTeq(Rotavirus)    		      
     6 Months   Growth & Development
    Check    		 Vaxelis(Dtap,Hib,Polio,Hep B), Prevnar20
    (Pneumococcal), RotaTeq(Rotavirus)    		      
     9 Months  Growth & Development
    Check    		        
     12 Months  Growth & Development
    Check    		 Prevnar 20 (Pneumococcal), MMR, Varicella    Hemoglobin, Lead  
     15 Months  Growth & Development
    Check    		   Pentacel (Dtap, Hib, Polio), Vacta(HepA)      
     18 Months  Growth & Development
    Check    		       MCHAT- Autism Screening
     2 Years  Growth & Development
    Check    		  Vacta (Hep A)    Hemoglobin, Lead   MCHAT- F/U Screening
     3 Years Growth & Development
    Check    		        
     4-6 Years Growth & Development
    Check    		 Proquad(MMR, Varicella), Daptacel(Dtap),
    Ipol(Polio)    		  Vision Screen    
     7 Years Growth & Development
    Check    		        
     8 Years Growth & Development
    Check    		        
     9-11 Years Growth & Development
    Check    		 Gardasil 9 (HPV, 2nd dose in 6m)      
     11 Years Growth & Development
    Check    		 Adacel(Tdap), Menquadfi(Meningococcal)      
     12 Years Growth & Development
    Check    		       Adolescent Depression/Anxiety
    Screen
     13 Years Growth & Development
    Check    		       Adolescent Depression/Anxiety
    Screen
     14 Years Growth & Development
    Check    		       Adolescent Depression/Anxiety,
    Alcohol & Drug Screen
     15 Years Growth & Development
    Check    		       Adolescent Depression/Anxiety,
    Alcohol & Drug Screen
     16 years  Growth & Development
    Check    		 Menquadfi(MeningococcalA),
    Bexsero(Meningococcal B, 2nd dose in 6m)    		     Adolescent Depression/Anxiety,
    Alcohol & Drug Screen. Females -
    STI Testing
     17 Years Growth & Development
    Check    		       Adolescent Depression/Anxiety,
    Alcohol & Drug Screen
     18 Years Growth & Development
    Check    		    Vision Screen   Screen for TB (if needed),
    Adolescent Depression/Anxiety,
    Alcohol & Drug Screen
     6 Months- 18 Years    Flu/COVID Vaccine (in season)      

  • Please note that CNY Family Care follows the vaccine schedule as recommended by the CDC Child and Adolescent Immunization guidelines. The schedules listed above are the minimum time intervals for which these vaccines may be administered and are subject for extension depending on Provider recommendation.

    Revised 10/10/2024

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