Online Pre-Registration
of Scheduled Tests/Procedures

**YOU CANNOT PRE-REGISTER ONLINE IF YOUR APPOINTMENT IS WITHIN THE NEXT 72 HOURS**

In order to pre-register on-line, you must know the date and time of your test or procedure.
If you have have issues or are unable to complete this form for any reason, contact the Pre-Registration department at 716-664-8440.
Required information is marked with a •

Section 1 - Patient Information
• Appointment Date: Please remember that you cannot schedule an appointment that is in less than 72 hours.
Click to select date
• Time of Appointment:
(Only scheduled tests/procedures can be pre-registered online)

Personal Information
• Patient Full Legal Name:  (Last Name)
,  (First Name, Middle Initial)
• Date of Birth:
• Social Security Number:  (no dashes please)
• Marital Status:
• Gender:
• Race:
• Address:
• City:
• State:    • Zip Code: 
• Telephone
(Including Area Code):		  (home)
 (alternate)
• E-mail:

Emergency Contact
• Emergency Contact Name:  (Last Name)
,  (First Name, Middle Initial)
• Emergency Contact Telephone
(Including Area Code):
• Relationship to Patient:

Employment Information
• Employment Status:
Retirement Date (if retired):  (mm-dd-yyyy)
Employer:
Address:
City:
State:    Zip Code: 
Section 2 - Insurance Information

PRIMARY INSURANCE

• Check to complete this section for your primary insurance coverage.
• Insurance Name:
• Name of Policy Holder:
• Policy Holder's Date of Birth: 
• Policy Holder's Social Security #:
  (no dashes)
• Relationship to Patient:
• Policy / ID Number:
Group Number:
(If provided) 
• Insurance Mailing Address:
(Submit claims to:) 
• City:
• State:    • Zip Code: 
• Insurance Phone Number:

ADDITIONAL INSURANCE #1

Check to complete this section if you have additional insurance coverage.
Insurance Name:
Name of Policy Holder:
(If other than patient) 
Policy Holder's Date of Birth:
(If other than patient) 		  (mm-dd-yyyy)
Policy Holder's Social Security #:
(If other than patient) 		  (no dashes)
Relationship to Patient:
(If other than patient) 
Policy / ID Number:
Group Number:
(If provided) 
Insurance Mailing Address:
(Submit claims to:) 
City:
State:    Zip Code: 
Insurance Phone Number:

ADDITIONAL INSURANCE #2

Check to complete this section if you have additional insurance coverage.
Insurance Name:
Name of Policy Holder:
(If other than patient) 
Policy Holder's Date of Birth:
(If other than patient) 		  (mm-dd-yyyy)
Policy Holder's Social Security #:
(If other than patient) 		  (no dashes)
Relationship to Patient:
(If other than patient) 
Policy Number:
Group Number:
(If provided) 
Insurance Mailing Address:
(Submit claims to:) 
City:
State:    Zip Code: 
Insurance Phone Number:

ADDITIONAL INSURANCE #3

Check to complete this section if you have additional insurance coverage.
Insurance Name:
Name of Policy Holder:
(If other than patient) 
Policy Holder's Date of Birth:
(If other than patient) 		  (mm-dd-yyyy)
Policy Holder's Social Security #:
(If other than patient) 		  (no dashes)
Relationship to Patient:
(If other than patient) 
Policy / ID Number:
Group Number:
(If provided) 
Insurance Mailing Address:
(Submit claims to:) 
City:
State:    Zip Code: 
Insurance Phone Number:
Section 3 - Guarantor Information

Check to complete this section if patient is a minor. Who is responsible for the bill after insurance has been paid?

Personal Information
• Guarantor's Full Legal Name:  (Last Name)
,   (First Name, Middle Initial)
• Date of Birth:
Social Security Number:  (no dashes)
• Address:
• City:
• State:     • Zip Code: 
• Home Telephone
(Including Area Code):

Employment Information
• Employment Status:
• Home Telephone:
Employer:
Employer Address:
 
City:
State:    Zip Code: 
Section 4 - Accident/Injury Details - Onset of Symptoms

Check to complete this section only if test/procedure ordered is due to an accident or injury.
Date of Accident: Click to select date
Time of Accident:
Location of Accident:
Type of Accident:

Check to complete this section only if test/procedure ordered is NOT due to an accident or injury
Please select one: Test/Procedure ordered for screening purposes (Wellness Exam)?
Date of last Doctor's appointment:
Test/procedure ordered is due to a medical condition
Date symptoms began:
Section 5 - About Your Visit
• Type of test/procedure:
• Physician Ordering Test:
• Family Physician (PCP):
•Reason for test exactly as listed on order (diagnosis):
 
For Uninsured Patients

Would you like to be contacted to determine whether you are eligible for free or low cost healthcare coverage?
Yes        No

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