New Patients
We welcome new patients to our practice. Please call our office to schedule a new patient appointment. (716)-859-7978. 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 HIPAA 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
Patient Responsibility Form
Financial Responsibility Form
HIPAA/Notice of Privacy Practices
Toileting Diary - No Volume
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
HIPAA/Notice of Privacy Practices
Financial Responsibility form
Toileting Diary w Volume
CUPID Packet
Release of Records
If you need a copy of your records, please complete the HIPAA Release of Records form and fax or mail it to us.
HIPAA/Notice of Privacy Practices
Medical Release
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