Canadian Patients - Kaleida HealthBuffalo, NY 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by reviewing the Financial Policy section. Ensure you understand your financial responsibilities, including copays and payment methods accepted.
3. Fill in your personal information at the top of the form, including your name and contact details. This is essential for accurate record-keeping.
4. In the Payment Information section, indicate your preferred payment method for copays. Remember that these are collected before seeing the doctor.
5. If surgery is necessary, acknowledge the cancellation policy by signing where indicated. This confirms your understanding of potential fees associated with missed appointments.
6. For minor patients, ensure that the legal guardian's information is filled out correctly to avoid any billing issues.
7. Finally, review all sections for accuracy before signing at the bottom of the form to confirm your agreement with the policies outlined.

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