This form will be valid until the patient listed turns 18. If there are any changes that need to be made a new form will need to be filled out. When patients turn 18 they will need to complete a new form themselves.
Would you like to receive appointment reminders and medical information via calls or texts?
If so, please list the name and phone number of the person that will be receiving these (only one person can be listed):
I attest that all the information I provided above is true and accurate to the best of my knowledge. I have received and am agreeable to the terms of Medical Health Associates of Western New York's privacy practices.