For patients new to our practice, please print the following forms*(No. 1, 2 and 3) and fill them out prior to your office visit. If time allows, please mail them to us at 897 Delaware Avenue, Buffalo, NY 14209 or arrive 15 minutes prior to your appointment time with the completed forms to expedite the registration process at your first visit.

Many of our patients have severe sensitivities to fragrances and their health is affected by the inhaling of scents.  Please refrain from wearing heavy colognes or perfumes when visiting our offices.

EFFECTIVE IMMEDIATELY:  

Please arrive to your appointment prepared to pay your copayment or deductible.  If you do not have your copayment with you, we reserve the right to reschedule your appointment.  Thank you.

ATTENTION PATIENTS:  

EFFECTIVE AUGUST 1, 2009, IN ORDER TO PROTECT YOU AND PREVENT INSURANCE FRAUD THE GOVERNMENT IS REQUIRING THAT WE OBTAIN PHOTO IDENTIFICATION ON ALL OF OUR PATIENTS. PLEASE BE SURE TO BRING YOUR DRIVER'S LICENSE OR OTHER FORM OF PHOTO IDENTIFICATION WTIH YOU TO YOUR APPOINTMENT.  THANK YOU!

TO ALL PATIENTS:

EFFECTIVE JANUARY 1, 2009

PLEASE COME TO YOUR APPOINTMENT PREPARED TO MAKE A PAYMENT FOR EACH VISIT IF YOUR INSURANCE COVERAGE REQUIRES THAT A YEARLY DEDUCTIBLE BE MET, OR THAT A CO-INSURANCE/COPAYMENT IS APPLICABLE.

IF YOUR DEDUCTIBLE HAS BEEN MET, WE WILL REQUIRE A COPY OF THE EXPLANATION OF BENEFITS SHOWING THAT THE DEDUCTIBLE IS SATISFIED IN ORDER TO WAIVE PREPAYMENT. 

TO ALL PATIENTS:

EFFECTIVE JANUARY 1, 2008

PLEASE ADVISE US OF YOUR NEED TO CANCEL AN APPOINTMENT AT LEAST 6 HOURS PRIOR TO YOUR APPOINTMENT TIME SO THAT WE MAY BETTER SERVE ALL OF OUR PATIENTS.

Effective January 1, 2008, there will be a $25.00 charge if we do not receive at least 6 hours advance notice for a cancelled appointment.

 Patient no-shows cause considerable hardship to our practice and patients who could otherwise be seen sooner.

 Thank you!

We look forward to seeing you!

1. NEW PATIENT INFORMATION SHEET 

2. RELEASE OF PROTECTED HEALTH INFORMATION
 

3. PATIENT HISTORY FORM OVER 14

                        ~ or ~

3. PEDIATRIC HISTORY FORM

If your medical bills are being paid through no-fault insurance:

1. NO FAULT INSURANCE FORM

2. NO FAULT ASSIGNMENT OF BENEFITS FORM

Having a special test done? Please print the questionnaire (s) and/or instructions!

VNG TEST INSTRUCTIONS

VNG HISTORY FORM

ABR INSTRUCTIONS

If you have records from another physician that would be helpful to our doctors, you can have your records transferred to us by printing & filling out the form below:

HIPAA MEDICAL RECORDS AUTHORIZATION

Read how your health information is protected. See our Summary of Privacy Practices below:

SUMMARY OF PRIVACY PRACTICES

*Note: All forms are Adobe Acrobat files. If you do not have Adobe Acrobat Reader you may download here for free: