Drs. Levitt & Appelbaum - Patient Forms

For your convenience we have provided several forms for your use. Please select the appropriate link needed for your visit. Print, fill out and bring with you at your next visit.

**If a child is under age 18 and will not be accompanied by the parent or legal guardian, they must have a signed permission slip allowing us to treat the child and list any medical conditions or medications. You can use our form by clicking on the link patient consent form below.

Patient consent form: Use this form if your child is coming to our practice without his/her legal guardian or parent.

Update form: Use this form if there are changes to your insurance, address and/or medical history and medications.

New Patient form: Use this form for your child’s first visit to our office. Complete entirely and bring with you on the day of your appointment.
New patients will need to print the HIPPA Compliance form.

HIPPA Compliance form: Use this form after you have read the HIPPA compliance information provided. Print and fill out. If you have more than one child you may put all of their names on the same form.

Records Release Form