Patient Forms

If you are new to Pomona Pediatrics or if it has been three years since you were last seen by us, we request that you print out and complete all of the following forms, and bring them with you to the office for your first visit.


To help provide timely service to our patients, we prefer to schedule all visits. If you arrive later than 10 minutes after your appointment time, we will try to work you back into the schedule, either with another provider or at a later time. However, we may need to reschedule your appointment.

In the event of telephone or power outages, you can reach our answering service directly at 1-888-819-0001.

Well Child Visits

Regular preventive care visits (also called “well child visits”) include a comprehensive history, age-appropriate screenings, a complete physical exam, and any necessary hearing and vision exams. Age-appropriate immunizations are also a part of these visits.

In New York, all insurance plans are required to cover these visits and immunizations. Some plans may not cover the recommended screenings, however, so payment for these screenings may be the your responsibility. We strongly suggest that you schedule your child’s next well child visit before leaving your current visit. During certain times of the year our schedule is full months in advance.

Walk-in Visits

We will do our best to fit in patients who walk in with a non-emergency condition, but our patients with scheduled appointments receive preference. Walk-ins may also be offered an appointment later in the day.

After-Hours Care

Our doctors take emergency calls from their homes after hours. To reach our on-call doctor, call the main office number and our answering service will page a doctor to call you back. On alternate weekends, our after hours coverage is provided by Dr. Joshua Chesir at 845–634–7900.

To receive a call back, you must disable “privacy protection” on your phone, or you will not receive our call. Please save any routine questions (mild illness, appointments, prescription refills) for regular office hours.

Emergency Care

If your child has an emergency, please call 911. Emergencies are conditions that are possibly life threatening, such as a loss of consciousness, severe bleeding or seizure. For minor emergencies (lacerations, cuts, mild fractures, sprains), please call our office first for instructions.

Payment Policy

Please have your card with you at the time of your visit. If we file your claim, you are responsible for only the co-pay at the time of visit, and any deductibles or co-insurance amount, as determined by the terms of YOUR insurance policy. Copayments are due at the time of the visit; a billing charge will be added if this payment is not made at the time of the visit.

Referral Information

We process referral requests in the order they are received. You must request a referral before your appointment with the specialist. Insurance company regulations prohibit us from backdating referrals after your visit.

Please call our referral line at 845-362-0205 and leave your name and telephone number, the patient’s name and insurance information, the physician for whom you need a referral, and the diagnosis or concern for the referral. Referrals are transmitted electronically for most insurance companies, and require a minimum of 48 hours for processing. If a paper referral slip is required, you will be notified when the slip is ready to be picked up. We regret that we cannot mail or fax referral forms.


4 Medical Park Drive
Suite C
Pomona, NY 10970
United States