Patient Appointment Checklist

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Name
First Last
DOB
MM slash DD slash YYYY
Appointment with Dr.
M.D. On
The office opens at 8:00AM.
1. Please bring insurance card. If referral is required, make sure it is in place prior to appointment.
Bring Cash, Check, or credit card for co-payments, co-insurance, and deductibles. Payment is expected at date of appointment. Esitmated amount
Additional charges if breathing test or allergy testing is done.
3. Arrive 15 minutes early to allow time to complete any paperwork not mailed to you. 4. If you want us to review any Labs done at another Doctor's office, Bring copies of reports with you. 5. We CANNOT promise testing on first visit. 6. Please do not bring children to your appointment unless the child is the patient. 7. If the patient is a minor and not accompanied by a parent, bring completed form:"Parent Designation to permit another person to consent for Health Care." We cannot see the patient without this permission from the parents. This form can be faxed or mailed to you before your appointment. 315-478-2339 is the number to call and ask for the form to be faxed or mailed. 8. Bring a list of ALL medications and include name, strength and dose of all medications.
Initials of responsible party
Please bring this checklist with you to the appointment.