NEW PATIENT INTAKE FORM

Before completing this form you will need:

• A confirmation number from the insurance company verifying the change of the Primary Care Physician (PCP) to this office.
• Insurance ID Numbers/Card

One form per child

Once this form is received, we will reach out for additional information needed and to schedule the first Well Child Exam at our office.

Please note, Patient records must be received prior to the scheduled appointment. Appointments will be rescheduled if they have not been received.

A NYS DOH Release of Health information form, can be printed from the Contact Us page on the website and submitted to the previous PCP. A release can also be filled out at your previous PCP office.

General information or questions about our office is available on the website or call our Well line at (716) 893-РEDS (7337)

Looking forward to setting up your first appointment soon!