Patient Forms & Payment Options

To help make your appointment run as smoothly as possible, we are putting some important forms here for you to download and fill out prior to your office visit.

At this time, we are working on the website and will have forms available for download shortly. Please contact our office at 716-671-2130. Thank you for your patience.

New Patient Forms

  • Patient Information
  • Patient History



All copayments are due at the time of service. If you request to be billed for your copayment, there will be an additional charge of $20 added to your bill.

We accept cash, personal checks*, MasterCard and Visa.

Financial Assistance

Please contact our billing office immediately upon receipt of your statement to avoid collection letters for non-payment.


If your account is in bad debt status and you have made no attempt at payment, we may suspend services until your account is made current.

*Please be aware there is a $20 fee for returned checks.


Subscribe to our e-newsletter and keep up to date with the latest tips, news, events and happenings from all of our trusted experts. Just submit your email address and we will keep you informed!

© 2016 Mark St. Marie

Home | About Us | Services  | Patient Education |  Forms |Blog |Contact Us