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For Your Visit

New Patient Forms

Our medical history forms and medical release forms are located on this website. Please fill out these forms prior to your visit to expedite the process. Email these forms with any test results (if electronic) to  zuckersinus@NSHS.edu.

New Patient History and Physical Form - Adults (download)
New Patient History and Physical Form - Pediatrics (download)

  • If you have scans and tests, please remember to bring them with you at the time of service.
  • All copayments are due at the time of service. Please bring credit card, check or cash.
  • If your insurance company requires one, please bring your referral with you on the day of your appointment.
  • All payments for aesthetic procedures are to be paid in full prior to surgery date.

Insurances Accepted

Aetna Inc
Anthem Health Plan
Cigna PPO
Empire BCBS
Empire Medicare 855I
Empire Medicare 855R
GHI Medicare 855I
GHI Medicare Group 855R
Local 1199
National Practitioner Identifier
Railroad Medicare
Select Pro
UHC Empire Plan