registration

In an effort to better serve you, Cityscape OB/GYN, PLLC is asking all patients to complete the forms below and either e-mail or fax them back BEFORE your scheduled visit.

If you are a New Patient to Cityscape OB/GYN. Fill out the form (PLEASE PRINT CLEARLY) and either e-mail or fax them over to our office A.S.A.P.

Please click on the PDF file that best describes your future office visit.

Please PRINT and COMPLETE these forms and bring the printout with you to your first appointment.

• PDF - New Patient Form - ALL FIRST TIME PATIENTS or patients who have not been here in three (3) years.
• PDF - All other patients, Annual Examination - Already established patients.

prescription refill

Please fill out the prescription refill request form below. For prescription renewals only.

Please click on the link below for a printable version of the form which can be faxed to our office.

• Prescription Refill - PDF

Once completed, fax the completed form to 212-683-1682. If there is a problem with your request, we will contact you at the phone number you provide. Please allow 2 business days for your prescription to be processed and transmitted to your pharmacy.

Remember: Please check with your pharmacy prior to picking up your prescription to ensure that it is ready.

medical records

Medical record release forms.

• Release of Information (NON-HIV) - PDF
• Release of Information (HIV ONLY) - PDF

Medical Records Policies

1. Medical Record Request must be in writing with the signature of the patient. Please click here to e-mail your request or click one of the two links below, print and fax to us at 212-683-1682.
2. Medical Record Request generally take three business days.
3. Medical Record Request will NOT contain confidential HIV results unless it is specified that they be released with the use of the HIV Only Release form found above.
4. According to the Public Health Laws of 1991, Chapter 165; amended Section 17 and 18, medical providers may charge $.75 cents per page. Your records will not be released until payment is received.
5. Medical records from other medical providers are not released. We ONLY release records for services performed at Cityscape OB/GYN, PLLC. For legal reasons, we do not release the records of third party medical service providers. It is recommended that you copy records from other service providers before giving them to us.