Patient Registration Form

Please correct the errors described below.

Patient Information



Primary Medical Insurance

Secondary Medical Insurance






Missed Appointments: Your appointment time is set aside especially for you. Resources are assigned for each individual patient. We ask that for the courtesy to the Doctor and to other patients that you keep your scheduled appointments.

If you must change or miss an appointment, we require a 24-hour notice. Failure to provide a 24-hour notice to cancel your scheduled appointment will result in a “no show” fee of $50.00 for office visits with Dr. Senchak or a $150 fee for specialty testing and procedures. A no-show fee must be paid prior to being seen at your next visit. Please note that insurance companies do not pay for no-show fees and therefore will not be billed for that charge.

Consent of Treatment: I authorize the staff at Texas Ear and Vestibular Institute to provide any diagnostic tests and examination indicated for treatment.

Disability or Insurance Forms: There will be a charge of $50 for the completion of medical forms. Payment is due at the time that you pick up the forms. Please allow 7-10 days for the completion of these forms.

Medication Policy Consent: I authorize Texas Ear and Vestibular Institute to obtain a medication history and/or list of current medications via my pharmacy for my medical records.


I hereby assign, transfer, and set over to Texas Ear and Vestibular Institute all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. All deductibles and copays are due at the time services are rendered and will be collected based on the information provided by your insurance company. I understand that charges not covered by my insurance company or my secondary insurance if applicable, as well as any applicable co-payments, coinsurance, and deductibles are my responsibility. If your insurance is with an HMO or other managed care program, Texas Ear and Vestibular will bill them only if you present an appropriate authorization form. If you do not have an appropriate authorization form for each visit, you will be responsible for all charges during that visit. If your insurance company has not paid your account in 90 days, the balance may be transferred to you for payment.

I understand that if I default on payment for services, my account may be transferred to an independent collection agency, designated as credit risk and payment for services will be required at the time of registration for all future visits. I have read the financial policy as above. I understand and agree to above financial policy.

We currently accept cash, Visa, Mastercard, Discover, American Express and Care Credit. Unfortunately, we are not accepting checks currently. If you have any questions regarding your bill, please contact our billing department at 469-625-2879.


I hereby authorize Texas Ear and Vestibular Institute to (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated during examination or treatment.

I have requested medical services from Texas Ear and Vestibular Institute. On behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for all charges incurred in the course of the treatment authorized.

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I understand that I have rights as a patient of Texas Ear and Vestibular Institute. I acknowledge that, upon request, I can request a copy of the Patient Rights and Responsibilities practices.

With my consent, Texas Ear and Vestibular Institute may use and disclose of my protected health information protected under Health Insurance Portability and Accountability Act of 1996 for treatment, billing/payment, and health care operations.

I understand that I have the right to request, now and in the future, how protected health information is used or disclosed to carry out treatment, payment, and health care operations.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Practice’s Privacy Officer. I understand Texas Ear and Vestibular Institute may refuse me further service if I revoke the consent.

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

Please list surgeries you have had, along with year if known

Add another list of surgery

Please list all medication that you take, along with dose (you may provide a separate list if you have one):

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Patients 65 years old and over ONLY:

Family History – please list any conditions that run in your family:

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