NAME


Patient Information - Child
(17 and under)

 
Demographic Info
Gender
Marital Status
Ethnicity
Preferred Language



People authorized to receive medical info:

Add another?
Has the child or anyone in the family been seen at our office before?
If the patient is a child under the age of 18, please list the guardians (who must be legal adults age 18 or older), other than the parents, who can seek medical treatment for this patient at our facility
Insurance Info
Do you have healthcare insurance
HIPAA: I have read and agree with the HIPAA Privacy information / Financial Policy: I have read and understand the financial policy.
I hereby authorize ENT Head & Neck Specialists to release and/or obtain information to/from insurance carriers, other physicians and/or medical facilities concerning my child's present illness/treatment and past medical history/treatment. I also hereby assign to the physicians of ENT Head & Neck Specialists all payments for medical services rendered to my dependents. I understand that I am responsible for any amount not covered by my insurance.
Medication Info
List all the medications (prescription/non-prescription) you are currently taking, including vitamins

Add another Med?
Are you allergic to any medication?
Have you had allergy testing?
Skin Test?
Blood Test?
Allergy Shots?
Past Medical History
Do you have any of the following?



















Is there a chance you are currently pregnant?
Have you or anyone in your family been seen by one of our physicians in the past?
Have you had a colonoscopy?
Have you had a pneumonia vaccination?
Have you had a influenza (flu) vaccination?
Have you had a mammogram?
Have you had a pap screening?
Surgical Procedures/Reason for Hospitalization

Add another Surgery?
Have you had any serious injuries, such as head trauma, broken bones, concussion, or loss of consciousness?
Do you or any member of your family have a history of problems with anesthesia?
Family History
Has any family member had any of the following: Heart Disease, Diabetes, Bleeding Disorders / Problems, High Cholesterol, Allergies, Stroke, Asthma, High Blood Pressure, Hearing Loss, Cancer and what type?

Add another History?
Social History
Do you smoke?
Do you consume alcohol?
Is there a personal history of substance abuse?
If the patient is a minor, is he or she exposed to cigarette smoke?
Do you CURRENTLY have any of the following?
Please check the medical symptom(s) below:





























Is there a personal history of hearing loss?
Medical Information Release
Release Information

Add another?
Messages - Please call
If unable to reach me

Responsible Party Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
LuxSci helps ensure HIPAA-compliance for email and web services.