Patient History Form

Patient Information
Patient Medical History

Please select if the PATIENT currently has or previously had any of the following

Please select all that apply.
Please add as many entries here as necessary. Additional fields will display as you type. Condition and Diagnosis Date
Facility / Date
Facility / Date
Please select all that apply.
Medications

Please list all medications the patient is currently taking

Please add as many entries here as necessary. Additional fields will display as you type.
Please add as many entries here as necessary. Additional fields will display as you type. Medication / Reaction
Upload Medication List. Only PDF, PNG, and JPG file types are accepted.
Family Medical History
Please select all that apply.
Please select all that apply.
Please select all that apply.
Please select all that apply.
Please select all that apply.
Social Behavior

Please indicate how often, if former indicate former.

How much and how often
How much and how often
How much and how often
How much and how often
How much and how often
How much and how often
For MINOR patients only

If PATIENT is a MINOR, please complete the following

Patient Insurance
Emergency Contact Information
Signature

I request that payment of authorized Medicare/Other Insurance Company benefits be made to me or on my behalf to The ENT Center for any services rendered by The ENT Center. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to be determine these benefits payable to related services.

Documentation
Driver's License. Only PDF, PNG, and JPG file types are accepted.
Insurance Card - Front. Only PDF, PNG, and JPG file types are accepted.
Insurance Card - Back. Only PDF, PNG, and JPG file types are accepted.
Additional Documents. Only PDF, PNG, and JPG file types are accepted.
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