Patient Forms

New Patient Form

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  • Patient Information

  • Insurance Information

  • Additional Information

  • Consent

    I give my consent for CENTC to discuss patient's medical care and payment for medical care with the following people:
  • Patients read and sign agreement

    1. I hereby give my consent for the physicians of Children's Ear, Nose and Throat Center (CENTC) to evaluate and treat the above patient.
    2. I have been provided with the Privacy Practices Notice for CENTC.
    3. I understand that my personal health information will be used for the purpose of treatment, payment and the coordination of health care needs of the patient.
    4. I have also been provided and agree with the Financial Policy of CENTC.
    __________________________________________________
  • First Responsible Party (Parent or Guardian of a minor under 18 or dependent child)

  • Second Responsible Party (Parent or Guardian of a minor under 18 or dependent child)

  • Divorced Parents

    In the case of divorced parents or shared custody arrangements, the court specifies the healthcare responsibilities for the child and boundaries of the involved parties. If the patient is a child of divorced parents or shared custody, please answer the following questions based on the court document that specifies the child's healthcare needs.
  • Consent for Minors or Dependent Adults

    IMPORTANT NOTE: On all initial consultations, the legal parent or guardian MUST BE PRESENT. Please state who may bring the child in for follow-up other than the legal parent or guardian.
  • THIS CONSENT REMAINS IN PLACE UNTIL REVOKED IN WRITING OR CHILD IS NO LONGER A MINOR
  • Medical History

  • Please indicate if ANYONE in the family has problems with the following:
  • Does your CHILD have any of the following problems?
    (If yes, please select score below)