New Patient Registration

These forms are available to help speed up the process of registering new patients. Please arrive 15 minutes early for your appointment in order to complete the registration process.

Submitting your information electronically by completing the fields shown below helps to speed up the registration process! You only need to arrive 10 minutes early if you complete the fields below and submit electronically.

IF SUBMITTING YOUR INFORMATION ELECTRONICALLY, ALL FIELDS WITH AN ASTERISK MUST BE COMPLETED OR YOUR FORM WILL NOT BE PROCESSED.

YOU MAY BE ASKED FOR YOUR PHOTO ID AND INSURANCE CARD AT EACH VISIT. ALL CO-PAYMENTS ARE DUE AT THE TIME OF YOUR APPOINTMENT.

Please bring the following information to your first visit:

  • Health insurance card
  • Driver’s license/photo ID
  • List of all medications you are taking
  • List of questions/concerns
  • Copies of records from doctors related to your sinuses/nose/allergies/lungs
  • CT imaging and report
  • Completed registration forms (see below)

If you recently have noticed decreased hearing, save a co-pay and schedule a hearing test at the same time as your appointment with your ENT physician.  Please call our office before you arrive for your appointment if you would like to schedule a hearing test.

Downloadable Forms:

Financial Agreement (please download form, complete, and bring with you to appointment) Please complete the following information and submit electronically. If you choose to not submit the information below electronically, you may download the Patient Information and Medical History Forms by clicking the following links:

Patient Information (only download, print and complete if you do not complete the information below and submit electronically)

Medical History (only download, print and complete if you do not complete the information below and submit electronically) To view ENT Specialists, PC, Notice of Privacy Practices, please click HERE.

New Patient Registration

  • Patient Information

  • Doctor/Insurance Information

  • *Please indicate your insurance carrier (check all that apply if more than one policy). Important Note: You should ALWAYS bring your insurance card to your appointment; co-pays DUE PRIOR TO BEING SEEN
  • Guarantor: Responsible Person for Paying Bill GUARANTOR: Person responsible for paying for services(Please put insurance holder here, if Medicaid list parent):
  • Primary policy holder's relationship to you: self, spouse, parent, etc.
  • Guarantor: Responsible Person for Paying Bill GUARANTOR: Person responsible for paying for services(Please put insurance holder here, if Medicaid list parent):
  • Secondary policy holder's relationship to you: self, spouse, parent, etc.
  • How did you hear about us?

  • Parent/Guardian authorization

  • Patient Medical History

  • Review of Symptoms

    Please check all CURRENT symptoms
  • Miscellaneous