Welcome to E.N.T. Surgical Associates
We look forward to seeing you for your appointment on
____________________________at _________.
Please find our patient registration and history form below. Please fill out completely.
Please bring the following information:
- Completed patient registration and history form.
- List of your current medications and doses.
- Previous CT scans, x-rays, or test results related to your current medical condition.
- List of drug and environmental allergies.
- Who referred you to our office? Name /Address/Phone
- Name of family doctor. Name /Address/Phone
- Current insurance card and picture I.D.
- Referral form (if you have Blue Care Network or any other HMO that is accepted by our office). A referral form from your primary care doctor must be with you at the time of visit before you may be seen by the doctor.
- If an auto accident or work related injury, please bring claim number, adjuster's name and telephone number, and address where claim should be sent.
**Please do not wear any perfumes, colognes, or aftershave as we have a fragrance free office (our office has a high volume of patients with severe allergies).
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 payments.
We look forward to seeing you. Please contact our office if you have any questions or need to reschedule your office visit.
*Please note* There will be a $10.00 fee charged to you for any scheduled appointments not kept.
Thank you,
E.N.T. Surgical Associates
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