Request an Appointment

Use the form below to request a call back for an appointment from your doctor’s medical secretary. Please indicate the patient’s name, phone number, e-mail address, preferred physician, type of appointment, date, time and reason for appointment. Do not e-mail any personal / private information.

Required Identification for Registration

The Federal Governments “Red Flag Rules for Health Care and Medical Practice” mandates that all our patients show a photo I.D. and we will match the I.D. against our patient file at every visit.

Request An Appointment

Patient's Name:

Phone Number:

E-mail Address:

Preferred Provider

Type of Appointment:

Preferred Date:

Preferred Time:

Reason for Appointment:

Disclaimer statement: You will be contacted within 48 business hours after DDAR receives your request; our staff will attempt to fulfill your request; however the exact day or time may not be available and a substitute may be offered to you. Do not use this form to send any personal / private information.

Digestive Disease Associates of Rockland, P.C.

Request an Appointment

Required Identification for Registration

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