WNYUA Online Services | New Patient Forms

Online Services

First of all, we would like to take a moment and welcome you as a new patient here at Western New York Urology Associates. Thank you for choosing us.

To save time at your first appointment, you may want to download and print this New Patient Information Form. Please bring this completed form with you to our office at the time of your visit.

You may also want to read this Welcome Letter, which includes some information about what else you will need to bring to your first appointment.

Additionally, you may wish to read over our Visions, Values and Expectations document which details what you can expect from us when you visit one of our locations.

Below are forms and additional items to bring when you visit our office:

Welcome Letter
New Patient Form/Review of Symptoms
Health Care Proxy
Patient Bill of Rights
Notice of Privacy Practices
Medical Records Release Form
Restriction of Use or Disclosure of Protected Health Information
Patient Responsibility Agreement/Referral Waiver - if you belong to an HMO and do not have a referral for a visit but still elect to receive care.
Workers' Comp Form
Notice Informing Individuals About Nondiscrimination and Accessibility
No-Fault Information Form
Official photo ID (e.g., passport, driver’s license)
A list of your current medications
Any imaging studies including X-ray films, CT scans and MRI scans from other groups or hospitals
Insurance information and card
Information about what treatments and medications have been used in the past
Medical records from other visits that you think may be helpful

To view the forms listed above, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com.

If you have any questions, please feel free to contact us at any time. Again, thank you for choosing Western New York Urology Associates.