New Patient Forms

Nobody likes paperwork, but it’s a necessary part of the process. Fortunately, with our convenient online form availability, you can download and print out your forms in advance to save time and make your visit even easier. 

Available Forms

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Complete History and Physical

On this form you should provide us with background information about any past surgeries and medical conditions. We also ask that you list all of your current medications and family history.

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Authorization for Release of Health Service or Treatment Information

This form allows your insurance company or payer of services to receive the information necessary to make payments.

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Patient Information Form

We use this form to collect general information about our patients in order to create a file for you on our computer system.

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Patient Prescription Information Form

We use this form to collect general information about our patients in order to create a file for you on our computer system.

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Financial Policy

We are committed to providing you with the best possible care and we are pleased to discuss our professional policies with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask any questions about our fees, financial policy or your financial responsibility.

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New Patient Forms (ALL)

This single file includes all other forms in one convenient download, making it easy to obtain everything you need for your first appointment at once.

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HIPAA Form

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Confidentiality Law. Under these laws the practice must obtain your written consent before it can disclose information about you for payment purposes. For example, the practice must obtain your written consent before it can disclose any Personal Health Information (PHI). In addition, you must also sign a written consent before the practice can share information for any and all treatment purposes.

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Colonoscopy Preparation Instructions

Better Health Care is Our Mission

Same Day Appointments are Available.

Phone:

716-434-6141

Fax:

716-434-0594

Email:

GreatLakesSurgery@Yahoo.com

Lockport Address:

160 East Ave.
Lockport, NY, 14094

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Kenmore Address:

2914 Elmwood Ave.
Kenmore, NY 14217

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Appointments in Kenmore Office available by request