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Forms

Appointment Pre-Registration

Please enter the below information and submit at least 48 hours prior to your appointment. Also review the packets below and if needed complete and bring with you to your appointment.

If you have an Authorization for Services, submit it to:

Rochester: [email protected]

Albany: [email protected]

    Appointment Information




    (If you are paying for your physical yourself, please note 'Private Pay')


    Patient Demographics









    Medical Follow-Up Forms

    Blood Pressure Follow-Up Form

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    Diabetic Follow-Up Form

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    Commercial Driver | Medical Follow-Up Form

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    Epworth Sleepiness Scale

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    Diabetes or Glucosuria | Medical Follow-Up Form

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    Firefighter Cardiovascular | Medical Follow-Up Form

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    Firefighter | Medical Follow-Up Form

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    Firefighter Diabetes | Medical Follow-Up Form

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    Firefighter Hypertension | Medical Follow-Up Form

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    Generic Medical Follow-Up Form

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    Hazmat Hypertension | Medical Follow-Up Form

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    Hazmat | Medical Follow-Up Form

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    Hypertension | Medical Follow-Up Form

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    Respirator | Medical Follow-Up Form

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    Sleep Apnea | Medical Follow-Up Form

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    Medical Questionnaires

    Asbestos Periodic Medical Questionnaire

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    Initial Asbestos Questionnaire

    Download Now
    Respiratory Fitness Questionnaire

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    Silicosis Surveillance History Questionnaire

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    Spanish Respirator Questionnaire

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    Physical Exam Packets

    19-A Physical Packet

    Download Now
    Non-DOT Packet

    Download Now
    DOT Physical Long Form

    Download Now
    OSHA Physical Packet

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    Employer Resources

    New Account Information

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    Background Check Authorization Form

    Download Now
    Audiometric History Form

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    Workers Comp and Urgent Care Packet

    Download Now
    Medical Information Release Form

    Download Now
    Authorization for Services

    Download Now
    Account Update Form

    Download Now

    Looking to make a payment?

    Sign into our payment system to easily pay your medical bills.