Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:

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1 Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S NAME: Date of Birth: ADDRESS: APT #: TOWN: STATE: ZIP PHONE (HOME): (CELL) OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE: PRIMARY PHYSICIAN: TOWN: PHONE: EMERGENCY CONTACT: PHONE: Relationship: PRIMARY INSURANCE: INSURED NAME: Birth Date: MEMBER ID#: GROUP#: Phone: SECONDARY INSURANCE: INSURED NAME: Birth Date: MEMBER ID#: GROUP#: Phone: RELATED TO ACCIDENT OR WORKMAN'S COMP, PLEASE COMPLETE SECOND PAGE IF YOUR INSURANCE REQUIRES REFERRALS, IT IS IMPERATIVE THAT YOU HAVE A WRITTEN OR TELEPHONE REFERRAL; FROM YOUR INSURANCE COMPANY PRIOR TO YOUR VISIT. I UNDERSTAND THAT IF I DO NOT HAVE A VALID REFERRAL FROM MY PRIMARY DOCTOR, THAT MY INSURANCE COMPANY COULD REFUSE TO PAY FOR MY VISIT. IF MY INSURANCE REQUIRES REFERRALS AND I FAIL TO OBTAIN A VALID REFERRAL. I AGREE TO ASSUME RESPONSIBILITY FOR PAYMENT OF SERVICES. I UNDERSTAND THAT INSURANCE CO-PAYS ARE DUE AT THE TIME OF MY VISIT. I UNDERSTAND THAT THE DOCTORS UTILIZE SCRIBES IN THE EXAM ROOMS AND I GIVE PERMISSION FOR A SCRIBE TO BE PRESENT DURING MY EXAMINATION. I UNDERSTAND THAT 24-HOUR NOTICE IS REQUIRED TO CANCEL MY APPOINTMENT(S) AND THAT I WILL BE CHARGED FOR A "NO SHOW VISIT' IF I FAIL TO CALL WITHIN 24 HOURS OF MY SCHEDULED VISIT. I HEREBY GIVE ASSOC. EAR, NOSE & THROAT SPECIALISTS PERMISSION TO RELEASE MY RECORDS TO MY OTHER DOCTORS AND TO MY INSURANCE COMPANY, INCLUDING PSYCHIATRIC, SUBSTANCE ABUSE, AND AIDS-RELATED INFORMATION. I HEREBY ACKNOWLEDGE THAT I HAVE BEEN GIVEN ACCESS TO A COPY OF THE NOTICE OF PRIVACY PRACTICES AND UNDERSTAND THAT I MAY CONTACT THE OFFICE MANAGER IF I HAVE FURTHER QUESTIONS OR COMPLAINTS; I ALSO UNDERSTAND THAT I AM ENTITLED TO RECEIVE UPDATES UPON REQUEST, IF THE NOTICE OF PRIVACY PRACTICES IS AMENDED OR CHANGED. SIGNED: DATE:

2 Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. WORKERS-COMP CLAIMS: EMPLOYER S NAME: SUPERVISOR: ADDRESS: TOWN: ST: ZIP CODE: EMPLOYERS PHONE: EMPLOYERS FAX: DATE OF INJURY: CLAIM NUMBER: INSURANCE COMPANY NAME: INSURANCE CLAIMS ADDRESS: TOWN ST: ZIP: INSURANCE CONTACT PERSON: PHONE: FAX: ATTY NAME: PHONE: FAX: AUTO ACCIDENT CLAIMS: DATE OF INJURY: CLAIM NUMBER: INSURANCE COMPANY NAME: INSURANCE CLAIMS ADDRESS: TOWN: ST: ZIP: INSURANCE CONTACT PERSON: PHONE: FAX: ATTY NAME: PHONE: FAX SIGNED: DATE:

3 PATIENT INTAKE FORM Pharmacy: Pharmacy Address: Allergies to Medications: Current Medications including vitamins, over-the-counter medications and supplements Medication Name: Dosage: Frequency: Method/Route: (Needle/Pill/Liq) Permission to Discuss Patient s Records I,, give Dr. Kevin Krebsbach and/or Dr. Todd Zachs permission to discuss my medical condition and any pertinent medical information with the following people: 1. Name Relationship 2. Name Relationship Patient-Signature Date

4 Name: Birth date: Please answer the following questions regarding your medical status and history: 1. Reason for today s visit: 2. Have you ever been treated for any medical conditions (Example: diabetes, high blood pressure, arthritis, etc.)? [ ] Yes [ ] No *If yes, please explain: Height: Feet Inches Weight: Do you currently have any of the following? If NO, please put an X / If YES, please Circle and Explain: Chronic fever, unexpected weight loss/gain, fatigue Eye (e.g. glaucoma, cataracts, retinal disease) Heart (e.g. chest pain, irregular heartbeat) Respiratory (e.g. shortness of breath, wheezing) Gastrointestinal (e.g. heartburn, abd pain, diarrhea) Urinary (e.g. pain or discomfort, blood in urine) Skin (e.g. skin cancer, rashes, excessive dryness) Musculoskeletal (e.g. arthritis, swollen joints) Neurological (e.g. numbness, weakness, headaches) Psychiatric (e.g. depression, anxiety) Endocrine (e.g. diabetes, hypothyroid) Blood/Lymph (e.g. anemia, cholesterol problems) Allergic/Immunologic (e.g. hay fever, lupus) Hearing loss Snoring, nosebleeds, runny nose Sinus problems, sore throat, recurrent infections Mouth sores, dryness, blisters 3. Have you ever had any surgery or been hospitalized? [ ] Yes [ ] No *If yes, please explain: Family History: Do any medical issues or diseases run in your immediate family? (E.g. heart disease, ear problems, hearing loss, sleep apnea, diabetes, high blood pressure, cancer, kidney disease, stroke, bleeding/immune disorder) [ ] Yes [ ] No *If yes, please list family member and disorder:

5 Acknowledgement Form Dr. Todd Zachs and Dr Kevin Krebsbach feel that patients presenting to our office with sinus, allergy, hearing, throat of voice complaints require a thorough examination of that specific area. In some cases, this can only be accomplished through an endoscopy, laryngoscope, cerumen removal (wax removal), etc. These examinations are a separate charge to insurance. These are essentially painless and in many cases, can be completed quickly. If we participate with your insurance company, you will be only obligated to pay any deductibles or co-payments that apply to this claim. Please note some insurance companies may list these diagnostic procedures as surgery on the insurance remittance form you will receive. These procedures have almost no risk and provide your physician with an excellent view of the areas involved. Please sign below to acknowledge that you have read and understood the above. Patient Name-Printed DOB Patient/Guardian Signature Date

6 Name: Marital: (CIRCLE One) Birth date: Single / Married / Divorced / Widowed / Other / DECLINED Employment: (Circle One) Employed / Self Employed / Unemployed / Retired / Student (full or Part time) / DECLINED Language: English / Spanish / Russian / French / DECLINED Other Race: White / Black / Hispanic / Asian / African American / DECLINED Other Ethnicity: Caucasian / African American / Italian / Spanish / Russian / DECLINED Other (Circle and Fill In) Do you smoke? Yes or No (If yes) how much? How many, Daily. How many, Weekly. How many, Monthly Only Socially, Monthly or, Yearly Did you Smoke? Yes or Never Smoked (if yes) When did you quit? Date: OR Number years ago? Do you drink alcohol? Yes or No (If yes) how much? How many, Daily. How many, Weekly. How many, Monthly Only Socially, Monthly or, Yearly Did you ever Drink Alcohol? Yes or Never Drank (If yes) When did you quit? Date: OR Number of years ago?

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