Rockland ENT Patient Forms

Please download the forms listed below and fill them out (all except signatures) using your computer keyboard or mobile device. This is best done by opening the downloaded forms in Adobe Acrobat Reader. You can then save the forms with your information and either

  • print them out, signing where indicated (in some cases a witness signature may also be required), and Fax them to our office at (845) 727-1349;
  • or attach them to an email message and send to sue@rocklandent.com. In that case, you can sign pages as necessary at your first appointment.

Please remember to bring to your first appointment:

  1. Active Insurance Card
  2. A photo ID
  3. An active referral, if needed
  4. X-rays, lab reports or other information that will make your visit more productive.

Download forms

You can download all the necessary documents here in one PDF (recommended) or you can download separately the following forms:

  1. Patient-Information.pdf
  2. Patient-Health-Information.pdf
  3. BMI-Stop-Bang.pdf (sleep apnea evaluation)
  4. Sino-Nasal-Outcome-Test.pdf
  5. ESS-Test.pdf (Epworth Sleepiness Scale)
  6. Cancellations-Payment-Medicare.pdf
  7. HIPAA-Statement.pdf

NOTE: See also Allergy Testing.