New Patient Registration Form

ENT ASSOCIATES MEDICAL GROUP

Please correct the errors described below.

Insured party (if different than above)

Please list with whom we can discuss your private health information:

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I ACKNOWLEDGE AND AGREE TO THE FOLLOWING:

I have reviewed a copy of the Notice of Privacy Practices of ENT Associates Medical Group. This Notice describes how ENT Associates may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

ENT Associates reserves the right to charge for broken appointments without 24 hours advance notice.
I hereby assign to ENT Associates all benefits provided by my insurance policy, not to exceed the charges for services rendered.
I am financially responsible for healthcare charges not covered by insurance.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Please list all surgical procedures and approximate years:

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Please list any other hospitalizations or major injuries:

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FAMILY HISTORY

Father

Mother

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Please select if you currently suffer from the following:

Medicine and Allergy List

Please list medications to which you are allergic or sensitive (Write "None", if appropriate):

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List the medicine that you are currently taking. Please remember to list presciption, over-the-counter, and herbal medicines. If regular doses of pain or anti-inflammatory medicines are used, list these. Also list topical medicines including drops, creams.

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