Welcome to Kips Bay Endoscopy Center

535 Second Ave, New York, NY 10016. Tel: 212-889-5477 Fax: 212-889-0525

Patient Satisfaction Survey

Pre-visit forms are required for your visit to the Center. Please either complete these forms online and print them, or print them and fill them out by hand.
Please bring these completed forms with you on the day of your appointment.

Note: Completing these forms online WILL NOT retain any record of your personal information. It is designed solely for your convenience, to help utilize your time with us most productively.
You will have to print a second copy if you want to keep a record of this information.

Patient Instruction Packet

Form(s) require Adobe Reader to view or print.

Notice of Privacy Practices

The pre-visit forms listed below are required for your visit to the Center. Please either complete these forms online and print them, or print them and fill them out by hand.

Please bring these completed forms with you on the day of your appointment.

Note: Completing these forms online WILL NOT retain any record of your personal information. It is designed solely for your convenience, to help utilize your time with us most productively. You will have to print a second copy if you want to keep a record of this information.

Welcome letter

Patient Registration Form

Pre-Endoscopy Questionnaire

Patient Information Sheet

Patient's Rights and Responsibilities

Uniform Assignment of Benefits Form

Notice of Privacy Practices

Patient Satisfaction Survey