New Patient Application

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

Board Certified in Family Medicine

This summer, new patients will be accepted in July only. No new patients will be accepted in August.

If you are interested in becoming my patient:

1) you must be referred by a friend or family member who is a current patient, or a physician.
2) I must accept your insurance (or self pay at the time of service)
3) you must be willing to use email as a primary mode of communication for routine matters (not for emergencies.)

If still interested, please contact me by filling out the form below.

Contact Information

I will respond to you by email as soon as possible (usually within 5 business days- if you don't get a response, please check your junk mail folder first! then call)

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Who referred you? What is your insurance? What is your birthdate? What are your medications? Anything else you would like me to know?	Enter answers here!