Urology Associates, P.C. - Urologists in Manhasset, New York


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Patient Forms

For your convenience we have added the following printable forms.

New Patient Forms	Surveys	Questionnaires
Procedure Instructions	Office Forms	Informational Forms

Note: Items marked as PDF format require Adobe Reader for viewing. If you have trouble, please consult PDF Help.

We wish to welcome you as a new patient. Below, please find various forms we require for your upcoming visit with the doctor. Please take a few minutes to complete the forms and bring them with you at the time of your appointment. You may give the forms to the receptionist when you check in.

At the time of your appointment, you must present your current insurance card. If you are a managed care patient, contact your primary care physician to obtain any needed referrals for this visit. If applicable, please be prepared to pay your co-payment and/or any co-insurance at the time of your visit.

New Patient Forms

HIPAA Designation Form (PDF)
HIPAA Privacy Statement (PDF)
Insurance Authorization (PDF)

Patient History Form (PDF)
Patient Information Form (PDF)
Pharmacy Information Form (PDF)

New Patient Surveys - Dr. Girardi
For new Male Infertility and Female Incontinence patients only.

Female Incontinence Survey (PDF)
Male Infertility Survey (PDF)

Patient Questionnaires

CT Scan Questionnaire (PDF)
Post-Urodynamic Questionnaire
Robotics FAQ (PDF)

Sling Surgery FAQ (PDF)
Urodynamics FAQ
DayOp Exit
Questionnaire

Robotic PostOp
Questionnaire
Male Infertility
Questionnaire
Incontinence
Quesitonnaire

PreOp Questionnaire

Existing Patients - Instructions

Contrast Reaction Instructions (PDF)
CT Scan Instructions
Indigo Laser Instructions (PDF)

Infertility Semen Analysis Instructions (PDF)
Kegel Exercises
No-Scalpel Vasectomy Instructions (PDF)
^{(Drs. Girardi, Goldberg, Johnson, & Bloom only)}

Post-Vasectomy Semen Analysis Instructions (PDF)
Prostatic Ultrasound/Biopsy Instructions
Recurrent Urinary Infections Instructions

Urodynamic Instructions (PDF)
Vasectomy Instructions (PDF)
^{(Drs. Mondschein & Fish only)}

Office Forms

24 Hour Referral Waiver (PDF)
Employment Application (PDF)
Medical Records Release Authorization (PDF)

Outside Medical Records Release (PDF)

Informational Forms

BCG Bladder Treatment (PDF)
Avoiding Post-Void
Dribble (PDF)
Frequency & Urgency (PDF)

Overactive Bladder (PDF)
Recurrent UTI (PDF)
Catheter Removal (PDF)

Foley Catheter
Removal Diagram (PDF)
Suprapubic Catheter
Care (PDF)
Kegel Exercises