New Patient Forms

ENTOffice.org, PLLC Medical History Form

*** Please complete ALL the information; if Not Applicable, please write “N/A” ***

Today’s Date:

Patient’s Last, First name

Date of Birth:

Person Completing Form and how you are related to the patient:

(if you are the patient, write “self”)

When was/will be your first visit with ENTOffice.org?

Regular (primary) Doctor:

How did you hear about ENTOffice.org?

If another doctor referred you, what is his or her name?

Why are you here today?

Medicines:

Do you/patient take any medicines?

Yes No

If you take more than 7 medications, please bring a list with you to your appointment

Add new row

Do you/patient have allergies to any medicines ?

Yes No

If “Yes”, what are they?

Explain what happens when you/patient have a bad reaction to medicine:

If there is a pharmacy where you want to get your medicine, tell us where::

Tobacco

Do you/patient use tobacco?

Yes No

What type?

How much?

When did you/patient start?

If you quit, how long ago?

Alcohol

Do you/patient drink alcohol?

Yes No

If yes, how much?

Could you/patient be pregnant now?

Yes No Not Sure

Has the patient ever had or been treated by a doctor for any of the following?

General

Chills

Yes No

Fatigue

Yes No

Fever

Yes No

Night Sweats

Yes No

Ear

Sensitive to loud sound

Yes No

Ringing ears/tinnitus

Yes No

Recurrent ear infection

Yes No

Hearing Loss

Yes No

Eye

Double vision

Yes No

Eye pain

Yes No

Sensitivity to light

Yes No

Vision changes

Yes No

Lymph

Large lymph “glands”

Yes No

Different sense of taste

Yes No

Nose

Nosebleeds (that keep coming back)

Yes No

Sinus Infections (that keep coming back)

Yes No

Allergy symptoms (that keep coming back)

Yes No

Throat

Scratchy voice (that keep coming back)

Yes No

Recurrent sore throats (that keep coming back)

Yes No

Difficult swallowing (that keep coming back)

Yes No

Neck

Painful neck swelling

Yes No

Painful neck movement

Yes No

Thyroid mass / swelling

Yes No

Lungs

Wheezing

Yes No

Cough

Yes No

Shortness of breath

Yes No

Coughing/spitting up blood

Yes No

Heart

Palpitations

Yes No

Chest pain

Yes No

Leg swelling

Yes No

Stomach/Intestines

Nausea/vomiting

Yes No

Abdominal pain

Yes No

Hepatitis A/B/C

Yes No

Heartburn or belching

Yes No

Joints

Jaundice (yellow skin/eyes)

Yes No

Arthritis (joint pain/swelling)

Yes No

Blood

Bleeding/clotting problems

Yes No

Easy bruising

Yes No

HIV/ AIDS

Yes No

Mental Health

Depression

Yes No

Anxiety

Yes No

Anesthesia problems in Surgery

Yes No

Sleep

Snoring

Yes No

Dizziness

Yes No

Gasping/choking (during sleep)

Yes No

Brain

Dizziness

Yes No

Light-headed

Yes No

Headaches (many)

Yes No

Loss of memory

Yes No

Weakness or can’t move

Yes No

Seizures

Yes No

Fainting

Yes No

Medical History— Please check “Yes” if the patient has EVER had any of these problems

Heart disease

Yes No

High blood pressure

Yes No

Asthma

Yes No

Other:

Are you/patient having any of these problems RIGHT NOW? If yes, what?

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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)

Anesthesia problems

Yes No

Long term ear infections

Yes No

Long term sinus infections

Yes No

Kidney disease

Yes No

Hearing loss

Yes No

Snoring or sleep apnea

Yes No

Liver problems

Yes No

Lung problems

Yes No

Stroke

Yes No

Thyroid problems

Yes No

Allergy

Yes No

Tuberculosis

Yes No

Cancer

Yes No

Diabetes

Yes No

Heart disease

Yes No

High blood pressure

Yes No

Bleeding problems

Yes No

Other:

Is there anything else we should know?

ENTOffice.org, PLLC Patient Registration Form

Today’s Date:

Patient’s Last, First name:

Street Address:

Phone:

City:

State:

Zip Code:

Last 4 SS #

Date of Birth:

Please allow us to contact you by Email:

Add new row

INSURANCE INFORMATION

**We will make a copy of insurance card and photo ID to help prevent insurance fraud**

Insurance Company:

Phone:

Member Number #:

Group #:

Effective Date:

Is the insurance in your name?

Yes No

If NOT, whose name is it under?

His/Her name:

Date of Birth:

Sex:

Male Female Other

Social Security Number:

Who can we call in case of an emergency?

Name:

Phone:

Permission to Use and Share Health Information

for Treatment, Payment, or Additional Care

I understand…

As part of my care, ENTOffice.org creates and keeps my health record. This record includes my health history, why I am being seen as a patient at ENTOffice.org, what I talk about with the doctor, nurse, or medical assistant, any tests I have done, and what the doctor plans for my treatment.
am giving permission for my insurance company to pay ENTOffice.org for any surgical and/or medical benefits available to me under my current insurance plan.
know that (unless I am covered by Medicaid) I am responsible for the part of my bill insurance does not cover.
Due to individual policies and plans, treatment may be subject to deductible and/or coinsurance. By signing this agreement, I acknowledge I am responsible for these charges.
have certain rights to privacy about my health information. This is because of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. I understand that by signing this form I give permission for ENTOffice.org to use and share my protected health information to do the following:

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.

ENTOffice.org has the right to change the terms of this notice from time to time and that I may contact you at any time to get the most current (up to date) copy of this form and the Notice of Privacy Policies.
have the right to ask for changes to (or limitations on) how my protected health information is used and shared in order to treat me, collect payment, and carry out other health care actions.  ENTOffice.org is NOT required to agree to the changes I ask for. However, if ENTOffice.org does agree, it must follow the changes I ask for.

I have also been informed of and given the right to review and secure a copy of the Notice of Privacy Policies, which:

Has a better description of the uses and sharing of my protected health information,
Talks about my rights under HIPAA.

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

Date

Print Patient Name

Relationship

Signature

Cancellation Policy/No Show Policy For Doctor Appointments and Surgery

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.

If an appointment is not cancelled at least 24 hours in advance you may be charged a twenty five dollar ($25) fee; this will not be covered by your insurance company.
If you no-show (do not show up) to an appointment without notifying us, you may be charged a twenty-five dollar ($25) fee; this will not be covered by your insurance company.
If you no-show to an appointment more than one time, we may send a note informing your regular doctor (PCP) and we will ask that you establish care somewhere else.

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.

If you arrive 15 minutes after your scheduled appointment time you may need to reschedule the appointment.
If you are late to your appointment 3 or more times, we may inform your regular doctor (PCP) and ask that you establish care somewhere else

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.

If surgery is not cancelled at least 48 hours in advance you may be charged a one hundred dollar ($100) fee; this will not be covered by your insurance company

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.

Patient Name (PRINT) :

Patient Signature:

Date

Your information will be encrypted.