Lockport Office:
39 Elizabeth Drive
Lockport, NY 14094
(716) 433-6004
Medina Office:
610 Park Avenue
Medina, NY 14103
(585) 798-0100

Patient Forms

Document Center

Please use the following forms before your first appointment or if your insurance information changes. Please print, fill out and bring with you to your next appointment.

Please contact us with any questions.

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 NOTICE OF NON DISCRIMINATION

Lockport Dental Group P.C. complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.  Lockport Dental Group P.C. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Lockport Dental Group P.C.:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

  • Qualified interpreters
  • Information written in other languages.

If you need these services, contact the Practice Administrator.

If you believe that Lockport Dental Group P.C. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Practice Administrator, 39 Elizabeth Drive, Lockport, NY  14094, P:716.433.6004, F:716.433.7547, email: lockportdental@lockportdentalgroup.com.

You can file a grievance in person or by mail, Fax or email.  If you need help in filing a grievance the Practice Administrator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at http://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of health and Human Services 200 Independence Ave. SW Room 509F,HHH Building Washington, D.C.20201, 800.368.1019,800.537.7697 (TDD).

Complaint forms are available at http://www.hhs.gov/orc/office/file/index.html.

We will take reasonable steps to provide free-of-charge language assistance services to people who speak languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about the dental care we are providing.

Spanish:

Tomaremos acciones razonables para proporcionar servicios de asistencia lingüística gratuitos a aquellas personas cuyo lenguaje escuchemos frecuentemente en nuestro consultorio y que no hablen un inglés lo suficientemente bueno como para hablar con nosotros sobre el servicio odontológico que suministramos.

Chinese:

我们将有序地做到提供免费的语言服务使我们能听懂英语不好的人向我们咨询有关牙齿护理

Russian:

Мы принимаем необходимые меры, чтобы предоставить бесплатные услуги переводчика для общения на языках, с которыми мы сталкиваемся в нашей практике с клиентами, которые не владеют английским языком достаточно, чтобы обсудить с нами стоматологическое обслуживание, которое мы предоставляем.

French Creole (Haitian Creole):

Nou pral pran mezi rezonab pou bay sèvis asistans lang gratis pou moun ki pale lang nou pagen ide deyo ak ki pa pale angle byen ase pou pale ak nou sou swen dantè nou ap bay.

Korean:

저희는 적절한 조치를 통하여 언어 지원 서비스를 무료로 제공할 것입니다. 다만, 실제로 저희에게 관심이 있는 언어를 쓰지만 저희 치아 관리 서비스에 대해 의견을 줄 수 있을 만큼 영어로 의사소통이 원활하지 않는 경우로 한정합니다

Italian:

Adotteremo le misure ragionevoli per fornire servizi di assistenza linguistica gratuiti a coloro che parlano lingue che sentiamo spesso sul posto di lavoro e che non parlano inglese abbastanza bene da poter discutere della cura dentale che stiamo fornendo.

Yiddish:

מיר וועלן נעמן פאראנטווארליכע מיטלן צו געבן פרייע שפראך הילף באדינונגן צו מענשן וואס רעדן שפראכן וואס מיר מסתמא וועלן הערן אין אונזר פראקטיק און וואס רעדן ניט ענגליש גוט גענוג צו רעדן מיט אונז וועגן דענטל הילף

Bengali:

দ াঁতের পররচর্য র রিষতে আম তদর প্র্য রিস চল ক লীন র্ র ইংর জী ভ ষ ে কথ িলতিন, এিং আম তদর প্র্দত্ত পররতষি ে র্ র ভ তল ভ তি ইংর জী ভ ষ ে কথ িলতে প রতিন ন , ে তদর জনয আমর রিন মূতলয ভ ষ র সহ েে প্র্দ ন কর র ক্ষেতে র্তথষ্ট দ রেত্বশীল পদতেপ গ্রহণ করতি ।

Polish:

Będziemy podejmować stosowne kroki, by zapewnić bezpłatne usługi wsparcia językowego dla ludzi, którzy rozmawiają językami, które my chcielibyśmy słyszeć w naszym gabinecie i dla tych, którzy nie mówią po angielsku na tyle dobrze, aby rozmawiać z nami o opiece stomatologicznej, którą zapewniamy

Arabic:

Arabic: سوف نقوم باتخاذ خطوات معقولة من أجل توفير خدمات المساعدة اللغوية بدون تكلفة لألشخاص الذين يتحدثون لغات أخرى من المرجح أن نستمع إليها خالل ممارستنا والذين ال يتقنون تحدث اإلنجليزية بشكل جيد يمكنهم من التحدث إلينا فيما يتعلق برعاية األسنان

التي نقدمها.

 French:

Nous prendrons les mesures raisonnables pour fournir des services d’assistance linguistique gratuits pour les individus qui parlent des langues que nous sommes susceptibles d’entendre durant nos séances et qui ne parlent pas suffisamment bien l’anglais pour discuter avec nous concernant les soins dentaires que nous fournissons.

Urdu:

ہم ان لوگوں کو جو ہماری پيش کردہ زبان بولتے ہيں ليکن انگريز ی نہيں جانتے اور ہم سے ڈينٹل کير کے ليے بات کرتے ہيں مفت زبان دانی کی امداد کے ليے معقول اقدام اٹهائيں گے۔

Tagalog:

Gagawin namin ang mga makatwirang hakbang para maibigay namin ng walang bayad ang mga tulong na serbisyo sa wika para sa mga taong nagsasalita ng mga wikang karaniwan naming naririnig sa aming pagsasagawa at sa mga hindi bihasa sa pagsasalita ng Ingles na sasangguni sa amin tungkol sa pangangalaga ng ngipin na ibinibigay namin.

Greek:

Θα λάβουμε όλα τα αναγκαία μέτρα ώστε να παρέχουμε υπηρεσίες γλωσσικής βοήθειας δωρεάν-χωρίς-χρέωση στους ανθρώπους εκείνους που είναι πιθανόν ότι θα μιλούν στη μητρική τους γλώσσα κατά τη διάρκεια της εξέτασης και οι οποίοι δεν θα μιλούν τα αγγλικά αρκετά καλά ώστε να συνεννοηθούν με εμάς για την οδοντιατρική φροντίδα που παρέχουμε. Albanian: Do të marrim hapa të arsyeshëm për të ofruar shërbime falas për asistencë gjuhësore për njerëzit që flasin gjuhë që ka të ngjarë të dëgjojmë në punën tone dhe që nuk flasin anglisht aq mire sa të flasin me ne për kujdesin dentar që ofrojmë.

Albanian:

Do të marrim hapa të arsyeshëm për të ofruar shërbime falas për asistencë gjuhësore për njerëzit që flasin gjuhë që ka të ngjarë të dëgjojmë në punën tone dhe që nuk flasin anglisht aq mire sa të flasin me ne për kujdesin dentar që ofrojmë