• 300 Garden City Plaza #312
    Garden City, NY 11530
  • Intake Forms

    Forms to Bring With You


    intakePlease print, fill-out, and bring with you any

    forms needed for your appointment. If you are unsure which forms to fill out, call our office at (516) 280-3544.

    General Intake Form – required for ALL new patients coming in for their first visit for private care or for an ED-180 program.

    Eating Disorder Intake Form – required for all new patients seeking eating disorder treatment for private care of the ED-180 program.

    Release of Information – this form should include all physicians, therapists, nutritionists, and other third parties that the patient agrees can release information and have communication with regarding his/her care.

    Bariatric Intake Form– required for all patients seeking bariatric surgery clearance.

    Permission to Treat a Minor– required to be filled out by parents or legal guardians of any new patient under the age of 18.

    In response to COVID-19 Please Note: Dr. DeSarbo and the ED-180 staff will be working remotely through the use of telemedicine until it is safe for patients and staff. While you may leave a message on the office phone, we prefer it if you can communicate through our office email DeSarbo312@gmail.com for appointments, refills, and other messages. Thank you and please be safe.