Home  
  Our Team  
  Patient Info  
  Services  
  CUPID  
Patient Portal Access

Patient Information

New Patients

We welcome new patients to our practice.  Please call our office to schedule a new patient appointment.  (716)-878-7393   Have your insurance card and pharmacy address ready during this phone call, as we will need to enter this information when you schedule your appointment. 

For your office visit
  • If your insurance requires a referral, you need to contact your child's pediatrician and request it.
  • Please bring your insurance card and co-pay.
  • We will collect your completed Patient History, Medication list, Financial Responsibility and HIPPA Review Confirmation forms.  If this is your first visit, you need to complete both pages of Patient History
For appropriate and thorough treatment of your child please have all paperwork completed prior to your appointment.
 
  • If we requested you return a toileting diary, please have it completed and ready during your visit.  This is an essential component in the appropriate management of your child.
  • If your child is toilet trained and seeing us for a urinary problem, we will collect a urine sample at this visit.  Please have your child ready to void when you check in.   Please have yourPlease
New Patient Forms

Patient History:    Page 1     Page 2 (Please complete both pages)

Medication list

Financial Responsibility Form

HIPPA form

Toileting Diary


Returning Patients


For your office visit
  • Please bring your insurance card and co-pay.
  • We will collect your completed Patient History forms and Medication list.  
If this is your first visit in over a year, you need to complete both pages of Patient History and the medication list.

If you have seen us in the past 6 months, you only need to complete the 2nd page of the Patient History and the medication list.


For appropriate and thorough treatment of your child please have all paperwork completed prior to your appointment.

 
  • If we requested you return a toileting diary, please have it completed and ready during your visit.  This is an essential component in the appropriate management of your child.
  •  If your child is toilet trained and seeing us for a urinary problem, we will collect a urine sample at this visit.  Please have your child ready to void when you check in.   


Returning Patient Forms

Patient History  Page 2

Medication list


HIPPA form

Financial Responsibility form


Toileting Diary


Release of Records

If you need a copy of your records, please complete the HIPPA Release of Records form and fax or mail it to us. 


HIPPA Release of Records 


 

 
Toileting Diary
New Patient History
Returning Patient History
HIPPA form
Medication list
HIPPA Release of Records
Financial Responsibility form
Surescript Consent
Self-identification Questions

Copyright HealthBanks, Inc. All rights reserved. | Terms of Use | Privacy Policy