ENTOffice.org, PLLC Medical History Form
*** Please complete ALL the information; if Not Applicable, please write “N/A” ***
Medicines:
If you take more than 7 medications, please bring a list with you to your appointment
Tobacco
Alcohol
Has the patient ever had or been treated by a doctor for any of the following?
General
Ear
Eye
Lymph
Nose
Throat
Neck
Lungs
Heart
Stomach Intestines
Joints
Blood
Mental Health
Sleep
Brain
Medical History— Please check “Yes” if the patient has EVER had any of these problems
FAMILY:Has a relative (by blood) ever had any of these problems?
If you answer “yes” to any of these, tell us who it was by writing next to the problem: GG (great-grandparent), G (grandparent), P (parent), S (sibling), C (child)
ENTOffice.org, PLLC Patient Registration Form
INSURANCE INFORMATION
**We will make a copy of insurance card and photo ID to help prevent insurance fraud**
If NOT, whose name is it under?
Who can we call in case of an emergency?
I understand…
o Treatment (the action, medicine, or therapy) ordered by the doctor
o Talk with other doctors or people responsible for my care
o Getting payment from my insurance company
o Showing my insurance company what the doctor did at my visit
o Making sure ENTOffice.org can measure the ability and effectiveness of the doctors, nurses, and medical assistants.
I have also been informed of and given the right to review and secure a copy of the Notice of Privacy Policies, which:
I understand that I may cancel or take back this permission, in writing, at any time. However, any use or sharing of my information that happened before I take back permission is not changed.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this
1. Cancellation/ No Show Policy for Doctor Appointment
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. On the other hand, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.
2. Late Arrival for Scheduled Appointments
We understand that delays can happen, but we must try to keep the other patients and doctors on time.
3. Cancellation/ No Show Policy for Surgery
Due to the large block of time needed for surgery, last minute cancellations can cause problems and added expenses for the office. This also prevents other patients from receiving necessary care/treatment.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.