Patient Forms

View policies, consents and download our procedure forms below.
You will be asked to sign for these at the time of registration at your office visit.

New Patient Forms

Are you a new patient? Download and complete New Patient packet AND complete
one of the questionnaires below which pertains to your medical problem.

New Patient Consult Form

Download the new patient packet below. Completion of this packet is required prior to first office visit.

Fibroid / Adenomyosis Questionnaire

If you are being seen for evaluation of fibroids or adenomyosis, please complete the Fibroid / Adenomyosis Questionnaire.

Back Pain Questionnaire

If you are being seen for back pain, please complete the Back Pain Questionnaire.

Leg Questionnaire

If you are being seen for evaluation of your leg(s) or feet, please complete the Leg Questionnaire.

Pelvic Pain Questionnaire

If you are being seen for evaluation of pelvic pain, please complete the Pelvic Pain Questionnaire.

AV Fistula Evaluation Questionnaire

If you are being seen for consideration of AV fistula creation, please complete the AV Fistula Evaluation Questionnaire.

General Forms & Notices

HIPAA Consent

HIPAA protects the confidentiality and security of a patients health care information therefore, it is required that we get your written consent for certain information.

Notice of Privacy Practices

This is our notice of privacy practices, which describes how medical information about you may be used and disclosed and how you can get access to this information.

HEALTHeLINK Consent Form

This consent form gives us authorization to access health information regarding my care and treatment through HEALTHeLINK.

Financial Policy

In order for our medical staff to be able to deliver the quality of care that you deserve and are accustomed to; we have established our financial policies. The link below will download a PDF list of guidelines that are necessary in order to continue to provide high quality care and make your visit as pleasant as possible.

Patient Bill of Rights

As a patient in a hospital in New York State, you have the right, consistent with law, to a bill of rights.

Surescripts Consent Form

Surescripts is an electronic database used to access your medication history. With your consent we will download list of your past and present medications to your personal chart. Knowing and understanding your medications is what makes us able to give you the best treatment, the treatment you deserve.

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