Rockland ENT Patient Forms
Please download RocklandENT-patient-forms.pdf and fill out (all except signature) using your computer keyboard or mobile device. (You can open the downloaded forms in a web browser or Adobe Acrobat Reader.) You can then save the PDF with your information and either
NOTE: You must sign the HIPAA Privacy Notice (page 1 of the combined forms), which you can do on your first visit to our office.
- print it out and Fax to our office at (845) 727-1349;
- or attach it to an email message and send to firstname.lastname@example.org.
Please remember to bring to your first appointment:
- Active Insurance Card
- A photo ID
- An active referral, if needed
- X-rays, lab reports or other information that will make your visit more productive.
You can download all the necessary documents in one PDF (recommended)
- Combined patient forms
or you can download individual forms using the following links:
- HIPAA Privacy Notice.pdf
- History Present Illness.pdf
- Medication Record.pdf
- Patient Health Information.pdf
- Patient Information.pdf
- Sino-Nasal Outcome Test_SNOT-22.pdf
NOTE: See also Allergy Testing.