General Form Download Instructions

To download the forms, simply right click on appropriate "Click Here to Download.." link and then select the "Save Target As.." option that appears on your menu.  Save the forms to a folder on your computer, and then use:  Adobe Acrobat Reader to view and print forms available in "PDF" format, or Microsoft Word for forms available in "RTF" (Rich Text Format).  The size of each file is indicated in parenthesis.

Please scroll down to see all forms available before you make your choice.

Please download, print, and complete the following forms if you are a new Internal Medicine patient to our practice. 

Patient Information Sheet

Click here to download this form in PDF format (22K)

Patient's Rights Sheet

Click here to download this form in PDF format (22K)

Patient's Responsibilities Sheet

Click here to download this form in PDF format (22K)

Patient History Sheet

Click here to download this form in RTF format (77K)
Sorry, this form not available in PDF format due to its large size

Please download, print, and complete the following forms if you are a new patient seeing Dr. Sameer Stas.

Patient Information Sheet

Click here to download this form in PDF format (22K)

Patient's Rights Sheet

Click here to download this form in PDF format (22K)

Patient's Responsibilities Sheet

Click here to download this form in PDF format (22K)

Endocrinology Questionnaire

Click here to download this form in PDF format (22K)

And

Osteoporosis Questionnaire  (If you have osteoporosis or calcium disease)

Click here to download this form in PDF format (22K)

Diabetes Mellitus Questionnaire  (If you have diabetes)

Click here to download this form in PDF format (22K)

All diabetic patients, please bring your home blood glucose meter and numbers.  For your convenience, you can download a "Blood Glucose Log" by clicking on the following link:
http://www.journeyforcontrol.com/journeyforcontrol/for_educators/documents/blood-sugar-log.pdf

Please download, print, and complete this form if you are seeing
Dr. Samir Shah.

Patient Information Sheet

Click here to download this form in PDF format (22K)

Patient's Rights Sheet

Click here to download this form in PDF format (22K)

Patient's Responsibilities

Click here to download this form in PDF format (22K)

Patient History Sheet

Click here to download this form in RTF format (77K)
Sorry, this form not available in PDF format due to its large size

And

Please download, print, and complete this form if you are a new pulmonary patient with a possible sleep disorder. 

Sleep Apnea Questionnaire

Click here to download this form in PDF format (22K)

Medical Record Release Form

Complete this form to indicate your consent to have your medical records transferred from Sussex County Medical Associates to another provider or other third party.

Click here to download this file in PDF format (8K)

Medical Record Send Form

Use this form to have records from another provider sent to Sussex County Medical Associates.

Click here to download this file in PDF format (6K)

If you do not already have Adobe Acrobat Reader you may download it free of charge from the Adobe web site.

Unless otherwise noted, all text, images, and encoding are:
Copyright © 2001, Sussex County Medical Associates, All Rights Reserved.