Mohammad Djafari, MD, FAAP  •  Erin Strong, C-PNP

Office: (607) 753-3051

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In order to help you more efficiently, we've made our forms available online. You can download and print these forms, and then fill out at your convenience before your appointment. We hope this will speed up your visit with us and give you more time to complete all questions accurately.

Our Offices

Patient Information Form
Please print and fill out this 1-page form and forward it to our staff in order to schedule your first appointment.
Click here to download: Patient Information Form

Release of Records
Patients who would like to release their information to Djafari Pediatrics, will need to provide permission, in writing. Please fill out this 1-page form and submit it to us via fax, mail or in person. Any staff member can assist with this.
Release TO us: TO Djafari Pediatrics
Release FROM us: FROM Djafari Pediatrics

Authorization for Emergency Treatment of Minors
Please download and print a copy (or copies) of our Authorization for Emergency Treatment of Minors. Fill in the information completely, one form for each child, and leave the form(s) with the person who you are placing in charge of their care. Don't forget to sign.

HIPAA Privacy Regulations
The Health Insurance Portability and Accountability Act (HIPAA) details can be found here. This policy is posted to ensure the confidentiality and security of your protected health information.

Your Patient-Centered Medical Home
Find out what "Your Patient-Centered Medical Home" is all about. Details can be found here.

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