PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING ADDRESS PATIENT S PHYSICAL ADDRESS STREET OR PO BOX CITY STATE ZIP CITY STATE ZIP COUNTRY COUNTY COUNTRY COUNTY USA USA OTHER OTHER PATIENT S CONTACT INFORMATION HOME PHONE # DAY PHONE # ALTERNATE PHONE E-MAIL ADDRESS PATIENT S EMERGENCY CONTACT INFORMATION NAME ADDRESS RELATIONSHIP CONTACT PHONE NUMBER PATIENT S ADDITIONAL INFORMATION MOTHER S MAIDEN NAME RACE LANGUAGE RELIGION ASIAN ENGLISH PACIFIC ISLANDER SPANISH BLACK OTHER CHURCH UNKNOWN NATIVE AMERICAN WHITE OTHER ETHNICITY MARITAL STATUS STUDENT STATUS VETERAN SMOKER HISPANIC ANNULLED FULL-TIME YES YES NON-HISPANIC POLYGAMOUS NOT A STUDENT NO NO UNKNOWN DIVORCED PART-TIME SINGLE INTERLOCUTORY WIDOWED LEGALLY SEPARATED LIFE PARTNER UNKNOWN MARRIED REFERRING PHYSICIAN PRIMARY CARE PROVIDER/PHYSICIAN NAME NAME CITY, STATE, AND ZIP CITY, STATE, AND ZIP OFFICE PHONE NUMBER OFFICE PHONE NUMBER FAX NUMBER FAX NUMBER RESPONSIBLE PARTY S INFORMATION (if different than above) NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SSN BIRTH SEX RELATIONSHIP TO PATIENT RESPONSIBLE PARTY S BILLING/MAILING ADDRESS STREET OR PO BOX RESPONISBLE PARTY PHYSICAL ADDRESS CITY STATE ZIP CITY STATE ZIP HOME PHONE NUMBER E-MAIL ADDRESS 1
PATIENT S EMPLOYER NAME OF EMPLOYER EMPLOYER S ADDRESS (Street, City, State and Zip) TYPE OF BUSINESS Patient Information LOCAL ADDRESS CORPORATE ADDRESS COUNTY OCCUPATION EMPLOYMENT STATUS FULL-TIME PART-TIME RETIRED DISABLED PRIMARY INSURANCE NAME OF SUBSCRIBER (Last, First, Middle) SUBSCRIBER S ADDRESS (Street, City, State and Zip) SUBSCRIBER S SOCIAL SECURITY NUMBER NAME OF INSURANCE COMPANY WORK PHONE RELATIONSHIP TO PATIENT POLICY NUMBER SUBSCRIBER S OF BIRTH GROUP NUMBER ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) SECONDARY INSURANCE (if applicable) NAME OF SUBSCRIBER (Last, First, Middle) SUBSCRIBER S ADDRESS (Street, City, State and Zip) RELATIONSHIP TO PATIENT EFFECTIVE POLICY NUMBER EXPIRATION SUBSCRIBER S SOCIAL SECURITY NUMBER NAME OF INSURANCE COMPANY SUBSCRIBER S OF BIRTH GROUP NUMBER ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) EFFECTIVE EXPIRATION ASSIGNMENT AND RELEASE I, the undersigned, have insurance with and assign directly to Dr. all medical benefits. I understand that I am financially responsible for all charges incurred. A copy of the back and front of my insurance card is required for billing purposes. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions. Sometimes healthcare information may be used for research, all such information is anonymous, and patient confidentiality is maintained. If you do not want any information to be used for research please check here. Signature of Insured Date CONSENT FOR TREATMENT I, the undersigned hereby authorize and give consent to Dr. for any x-rays examinations, laboratory tests, and treatment rendered to the patient named above. Signature Date MEDICARE AUTHORIZATION I request the payment of authorized Medicare benefits be made directly to me or the physician rendering services. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier. Signature Date 2
Please be advised, it is the patient s responsibility to ensure that the physician they see is contracted with their insurance plan. Medical Conditions: Do you have any of the following medical conditions? Condition No Yes If yes, when was it diagnosed? Head & Neck Allergies Chronic Sinusitis Middle Ear Infection Acid Reflux Snoring Sleep Apnea Hearing Problems Balance Disorders Voice Problems Swallowing Disorders Chronic Stuffy Nose Head & Neck Cancer Nose Bleed Ringing in the Ears High Blood Pressure Diabetes Coronary Artery Disease/Heart Attack Congestive Heart Failure (CHF) Aneurysm (List Location) Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Chronic Obstructive Pulmonary Disease (COPD) Asthma Stroke Headaches (List Type) Seizure Disorder/Epilepsy Hepatitis B Hepatitis C HIV Hyperthyroid Hypothyroid Lupus Arthritis Osteoporosis Chronic Back or Neck Pain Chronic Liver Disease Bleeding Disorder (List Type) Stomach or Intestinal Ulcers Other (Please Specify) 3
CHRONIC PROBLEM LIST Chronic Problem Onset Date PAST MEDICAL/SURGICAL HISTORY Procedure Year FAMILY HISTORY (Please List only Mother, Father, Brother, and Sister) PATIENT ADOPTED NO RELEVANT FAMILY HISTORY Diagnosis Family Member Name Age Onset or Age Death Comments SOCIAL HISTORY Uses Tobacco: Currently Never Formerly Unknown Alcohol Use: Yes No Formerly - Year Quit Type: Chewing Cigar Cigarettes Pipe Smokeless Snuff Recreational Drug Use: Currently Formerly Never Unknown Marijuana IV Other If "YES" Type of Alcohol Frequency When was Last Drink Caffeine Use: Yes No Units/Day: Type Years Used: Amount Daily 4
PATIENT S INFORMATION NAME (Last, First, Middle) PREFERRED PHARMACY (Name, Address, Phone Number) BIRTH BACK UP PHARMACY (Name, Address, Phone Number) REASON FOR VISIT Patients Injury/Illness: 1. 2. Onset Date: Rate of Pain(0= no pain; 10= most severe) 1 2 3 4 5 6 7 8 9 10 3. ALLERGIES (Medication(s), Environmental Issue(s), and Food(s)) Item(s) that you are allergic to: Reaction(s) you have had from the Allergen, you are allergic to: MEDICATIONS AND SUPPLEMENTS THAT YOU TAKE ON REGULAR BASIS Drug Name (Brand name, or generic name) Dosage Times taken within 24 Hours Reason for taking Medication 5
Procedure Acknowledgement In Order to diagnose your condition appropriately, the doctor will often perform an endoscopy or laryngoscopy. These procedures, as well as any earwax (cerumen) removal, foreign object removal, or any other procedures are not included in the cost of your regular examination and you will likely incur additional charges. If you have insurance, these charges are usually in addition to your co-pay and subject to your deductible. These procedures are considered surgical procedures. Endoscopy and Laryngoscopy are procedures where a scope("camera") is inserted into your throat or nose, to aid the doctor in diagnosing your condition. If you do not want or consent to having these procedures performed, you must immediately notify the doctor so they can document your denial in your visit today. Patient's Printed Name Date of Birth Patient/Legal Representative Signature Representative Relationship Date 6