• Ear Nose and Throat Patient Registration Form

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Taking any medications, currently?
  • Past and current medical history (check all that apply)
  • Please check the boxes below if you have any family history of the following diseases
  • Please check if you currently have any of the following symptoms:
  • Have you ever smoked tobacco?
  • Do you drink alcohol?

  • SINO-NASAL OUTCOME TEST      

  • Below you will find a list of symptoms and social/emotional consequences of your rhinosinusitis.  We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability.  There are no right or wrong answers, and only you can provide us with this information.  Please rate your problems as they have been over the past two weeks. Thank you for your participation. Do not hesitate to ask for assistance if necessary.
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  • A Notice to Our Valued Patients

    During your visit in our ENT department, your physician may find it necessary to use endoscopes (special lighted instruments) as part of their evaluation. This will enable your physician to provide you with the most thorough examination of your sinuses and throat when needed. Although, this is fairly routine for our specialty, most insurance companies consider this a "surgery" or "in-office procedure" and it may be reflected as such on your billing statement or explantion of benefits. In addition, your physician may also require you to have an Audiogram, also known as a hearing test. Each of these services will result in an additional charge and therefore an additional financial responsibility for you. We want you to be informed of these services so there are no surprises or concerns after you leave our office.  

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