Amherst Pediatrics: Buffalo, Amherst, Cheektowaga & Tonawanda NY Pediatric Center

Please complete the form below and press submit. If there is a problem with your referral request or we need more information we will contact you by phone.

All requests will be processed within 48 hours during regular business hours Monday-Friday 8:30 am-4:30 pm. If you require immediate assistance, please contact the office at 632-2729.

You will be sent an email when the referral is complete.

Patient Information

*First Name:

*Last Name:

*Date of Birth (MM/DD/YYYY):

*Home Phone:

*Daytime Phone:

*Email Address:

*Ordering Provider:

Referral Information

*Physician to be seen:

*Address of Physician:

*Specialty:

*Insurance:

*Insurance Policy ID#:

*Appointment Date:

*Condition/Diagnosis: