Pediatric and Adolescent Medicine
44 Godwin Avenue
Midland Park, New Jersey 07432
Fax (201) 444-2309
Your health/child’s health is very important to this office, as well as your time. We recognize that unavoidable emergencies do occur. If for any reason you need to reschedule an appointment, please call this office within 24 hours to allow us the opportunity to schedule another patient. Missed appointments with little or no notice may result in charges.
We appreciate your understanding and anticipated cooperation in this matter.
Parent’s Signature Date
Patient’s Signature (if 18 or older) Date
To print out this form, click on the link below.
Deborah L. Ungerleider, MD, LLC
44 Godwin Ave Suite 100
Midland Park, NJ 07432
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