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 PDF with your information and either

  • print it out and Fax to our office at (845) 727-1349;
  • or attach it to an email message and send to
NOTE: In the combined PDF, pages 4, 5, 6, 7 and 9 require you to sign them, which you can do on your first visit to our office.

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. BMI-Stop-Bang.pdf (sleep apnea evaluation)
  2. Sino-Nasal-Outcome-Test.pdf
  3. ESS-Test.pdf (Epworth Sleepiness Scale)
  4. Cancellations-Payment-Medicare.pdf
  5. Privacy-Notice.pdf

NOTE: See also Allergy Testing.