Forms

Printable Office Forms

Prior to your appointment, the forms listed below can be printed for your convenience. Filling them out beforehand will save you time by not having to complete them during your appointment. If you elect not to fill out these forms ahead of time, please arrive 15 minutes prior to your scheduled time. (You may download Adobe Reader for free at www.adobe.com.)

  • Antibiotic Policy

    We work hard to not overuse antibiotics.


    We educate families on appropriate use of antibiotics, but follow evidence-based guidelines and don’t automatically treat ear pain or a green snotty nose with antibiotics.


    We do not routinely prescribe antibiotics over the phone as we do not believe that is good medicine. We will prescribe an antibiotic when we believe it is an appropriate treatment.

  • Appointment Policy

    Everyone's Time is Equally Valuable.


    We ask that you arrive 5 minutes before your scheduled appointment time. We understand sometimes things happen beyond your control that may cause you to be late. However, we reserve the right to ask you to reschedule if you arrive late for your appointment.


    Our practice makes every effort to run on time with appointments, as we believe everyone’s time is equally valuable.


    Upcoming Appointments Via Phone/Text Message/Email


    Missed Appointments: Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. We reserve the right to charge a fee for canceled or missed appointments. We request 24 hours notice for cancellation of appointments.


    A fee may be charged for a second missed appointment. The third consecutive missed appointment will result in discharge from the practice.


    For new patients, a fee may be charged if the FIRST appointment is missed.

  • Financial Policy

    East Aurora Pediatrics Financial Policy
  • Insurance

    Payment and co-pays are expected at the time of the visit. Please speak with our account manager if special payment arrangements are necessary. Most insurance companies require you to name one pediatrician as your primary care provider: you are free, however, to see any of our providers.


    We accept most insurance plans. Please call for more information.

  • Privacy Policy HIPAA

    This PDF provides information about our privacy practices.

    Download PDF
  • Referrals

    If you feel that your child needs a referral to a specialist, please call our office. Referrals are best accomplished through your primary care provider.

  • Technology Policy

    Efficiency through the use of technology


    You will be encouraged to consult our website, register for and use our patient portal, and effectively use automated reminders for appointments and for routine care/immunizations that are due.

  • Vaccine Policy

    East Aurora Pediatrics firmly believes that vaccinating children and young adults is one of the greatest successes of modern medicine. Most vaccines are 90-99% effective in preventing disease. The science is overwhelming that vaccines are safe and effective.


    Our office believes that all children should receive the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.


    If, despite all the evidence in favor of vaccines and as a parent, you still refuse to vaccinate your child, East Aurora Pediatrics will not be able to accept your children into our practice where they might put another child in harm’s way.

  • Workman's Compensation and No Fault Insurance Claims

    We do not participate in Workman’s Compensation. We do participate in No Fault claims.

Policies