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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

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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

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Non-DOT Packet

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DOT Physical Long Form

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Silica Physical Packet

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Employer Resources

New Account Information

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Background Check Authorization Form

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Audiometric History Form

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Workers Comp and Urgent Care Packet

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Medical Information Release Form

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Authorization for Services

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Account Update Form

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Looking to make a payment?

Create an InstaMed Account and simplify the way you manage and pay
your healthcare bills for all of your providers and family members.