New Patient Info
Welcome to E.N.T. Surgical Associates
In order to make your initial visit to our offices as efficient as possible, please bring the following information with you:
1. Completed patient registration and history form. (Download and Print Below)
2. List of your current medications, doses, and complete pharmacy information.
3. Previous CT scans, x-rays, or test results related to your current medical condition.
4. List of drug and environmental allergies.
5. Who referred you to our office? Name/Address/Phone
6. Name of family doctor. Name /Address/Phone
7. Current insurance card and picture identification must be presented at every visit.
8. If applicable, a referral form or written notification from your primary care doctor must be with you at the time of visit before you may be seen by the doctor.
9. If the reason for your visit is due to an auto accident or work-related injury, please bring your insurance company name, claim number, adjuster's name, telephone number, and an address where claims should be sent.
**Please do not wear any perfume, cologne, or aftershave, as we are a FRAGRANCE-FREE office.
Payment is expected at the time of visit on all copays, deductibles, and self-paying patients. For your convenience, we accept cash, check, or Visa/MasterCard/Discover.
We look forward to seeing you. Please contact our office if you have any questions.
*Please note* There will be a $10.00 fee charged for any appointment not cancelled within 24 hours.
Thank you,
E.N.T. Surgical Associates
New Patient Form
Patient History Form
Pharmacy Form
The HIPAA Notice of Privacy Practices
Privacy Notice Acknowledgement
E. N. T. Surgical Associates, P.C.27483 Dequindre Road, Suite 201
Madison Heights, MI 48071
Phone: 248-541-0100 Fax: 248-399-3960
28080 Grand River Avenue, Suite 205 W
Farmington Hills, MI 48336
Phone: 248-478-8616 Fax: 248-478-0138
28295 Schoenherr Road, Suite B
Warren, MI 48088
Phone: 586-751-6990 Fax: 586-558-5752
4160 John R, Suite 805
Detroit, MI 48201
Phone: 313-831-1444 Fax: 313-831-8307
1030 Harrington, Suite 105
Mt. Clemens, MI 48043
Phone: 586-751-6990 Fax: 586-558-5752
50505 Schoenherr, Suite 300
Shelby Township, MI 48315
Phone: 586-997-3099 Fax: 586-726-8085
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