Access Secure Online Patient Forms
Before your appointment with us, quickly and conveniently access patient forms from our practice.
Your request will be processed within 24 hours, during normal business hours, Monday – Friday, 8:00 am – 4:30 pm, excluding holidays. If you do not receive confirmation of your request within 48 hours, please contact our office at 716-691-3400.
Online Patient Forms
“No Show” Policy Acknowledgement
Designation of Another Person To Consent For Treatment
Financial Policy Acknowledgement
Notice to Revoke “Designation of Another Person to Consent for Treatment”
Request to Obtain Records / Release of Information Authorization
ASQ Developmental Questionnaire
The ASQ is a validated developmental screening tool that we review at the following ages: 9 months, 18 months, and 30 months. These screeners help determine if there are delays in key areas of a child’s development.
MCHAT – Autism Screening Tool
The Modified Checklist for Autism in Toddlers (M-CHAT) is a validated developmental screening tool for toddlers between 16 and 30 months of age.
Forms for New Patients
Please review the following policies before you complete these forms: Financial Policy, Vaccine Policy, Privacy Notice.
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