Dr. Jennifer Sacks
Dr. Angela Pericozzi
Katherine Smith, PNP
Kaitlyn Cornman, PA-C
5116 W. Taft Road
Liverpool, NY 13088
Phone 315-458-6601
Fax 315-458-7940
Office Hours:
Monday-Thursday 8:30AM - 5:00PM
Friday 8:30AM - 4:00PM
Saturday 9:00AM - 11:00 AM
Saturday's are by appointment only; please be sure to call at 8:30am to schedule an appointment as we may close early if there is no demand.
Forms:
This page contains all the new patient forms provided at your first appointment. If you can print and bring them with you, you'll be ahead of the game!
Also included is the medical records request form, which can be sent to your child's current primary care provider.
We’ve also provided Vanderbilt Forms for ADHD screening.
If you need assistance viewing, printing, or filling out these forms, please don’t hesitate to contact our office, and a staff member will be happy to help!
PDF Forms:
Parent Vanderbilt Form.
This form is the Parent Vanderbilt
form which is used to screen ADHD
This form is the Teacher Vanderbilt
form which is used to screen ADHD
Medical Records Release Form Transitioning TO BRP
This form is a NYS form that is intended for the release of medical records from your previous medical office transitioning to Buckley Road Peds.
Medical Records Release Form Transitioning FROM BRP
This form is a NYS form that is intended for the release of medical records from Buckley Road Pediatrics transitioning to your next medical office.
This packet holds blank forms created by the staff of Buckley Road Pediatrics, PLLC. Inside, you'll find:
- Demographic
- Medical History
- TalkSoft Agreement
- Privacy Agreement
- Patient Responsibility
If you wish to complete these form ahead of time before your first appointment you can print out the form and bring everything to your child's first appointment.