Please select if the PATIENT currently has or previously had any of the following
Please list all medications the patient is currently taking
Please indicate how often, if former indicate former.
If PATIENT is a MINOR, please complete the following
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.