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BridgeSpan medicine
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  • Meet Our Providers
    • Patricia Avvocato, MD
    • Wei Chen, MD
    • Kerry A. Godfrey, MD, FAAP
    • Erin Kelleher, MD
    • Mary Woo, MD, FAAP
    • Carol Wurzel, MD
  • Services
    • Adolescent Medical Care
    • Mental Health
    • Sexual Wellness
    • Wound Care
    • Covid-19
    • Respiratory Care
  • On-Site Services
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Forms

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) 698-5544.  See below for forms to complete.

PATIENT REGISTRATION FORMS

BridgeSpan Medicine 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 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.

Interactive Forms:

  • Patient Registration
  • Financial Policy

Existing Patient

Downloadable Forms:

  • Patient Registration
  • Health 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.

 

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Address:
3010 Westchester Avenue,Suite 307
Purchase, NY, 10577

Phone: (914) 698-5544
Fax: (914) 761-1711

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BridgeSpan Medicine in Purchase, New York, offers pediatric and adolescent services including Adolescent Medical Care, Sexual Wellness, Respiratory Care, Mental Health, Wound Care, and Covid-19 testing.