New Patient Registration

Naureen A. Mohamed M.D.
5820 Main Street Suite 314, Williamsville, NY 14221 716-633-3323

Board Certified in Family Medicine

New Patient Registration- only if you have been accepted by Dr. Mohamed (received email from doctor saying you have been "accepted")

New Patient Registration

1-Please fill out the registration below and PRINT out and bring in the paperwork listed: Payment policy, Email Consent and Assignment of Benefits/ Privacy Policy. Fill out the Credit Card Authorization Form if you have a high deductible policy. ( If you forget it, you will spend part of your appointment time filling it out. )

2-Please bring your insurance card and your copay to your appointment. If you have Univera, Independent Health, Community Blue or Traditional Blue PPO, please call your insurance company and request me as your PCP (primary care physician) before you come in. Tell them the date of your appointment and get a confirmation number. If you forget to call before your appt, you will spend part of your appointment time calling.

3-Please read about prescription refills and forms.

4-OK, now you can make your appointment online! Click on the link below.
Please be on time, I will really be ready for you on time!

New patient registration

Please fill in for each new patient. Thank you.

First Name:
Last Name:
Birthdate:
Gender (Answer M or F):
Pharmacy Name and Address:
Relationship Status (single, married etc)
Insurance Confirmation Number: showing that you listed me as your PCP (if you have Community Blue, IHA or Univera)
I Reviewed the Prescription Refill Policy (answer Answer Y/N)
I Reviewed the Forms policy (answer Answer Y/N)
Emergency Contact Name and Phone:
Women, name of OB/GYN (if you have one)
List your specialists:
I understand communication will be mostly by email (except in an emergency) Answer Y/N
It is OK to call home and leave a detailed message Answer Y/N:
It is OK to call my workplace and leave a detailed message: Answer Y/N
It is OK to call my cell phone and leave a detailed message Answer Y/N:
It is OK to mail to my home Answer Y/N:

Forms (will open in a new page)

New Patient Forms

Authorization for Release of Medical Records (to have records sent to Dr. Mohamed) helpful, not required, please mail/fax to your previous doctor

Payment policy Form (2 pages)- required
Email Consent Form (1page) - required
Assignment of Benefits Form and Privacy Policy (1 page)- required

Credit Card Authorization Form- required if you have a high deductible policy

Prescription Refills- read only
Forms and Non covered Charges- read only

Appointment Scheduler- will open in a new page. You will need to make up a user name and password. Make sure you get a confirmation number, or your appointment was not saved!

Click here to register and make an appointment

Free download of Adobe Reader (needed to read above forms)