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  • Patient Information

  • Name * Required
  • Address * Required
  • Sex * Required
  • Insurance Information

  • Name of Policy Holder * Required
  • Name of Policy Holder
  • Additional Information

  • Pharmacy Address
  • Consent

    I give my consent for CENTC to discuss patient's medical care and payment for medical care with the following people:
  • Name
  • Name
  • Name
  • 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)

  • 1st Guardian's Name * Required
  • Address * Required
  • Second Responsible Party (Parent or Guardian of a minor under 18 or dependent child)

  • 2nd Guardian's Name
  • Address
  • 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.
  • Name
  • Address
  • Name
  • Address
  • Name
  • Address
  • Medical History

  • Medication Allergies * Required
  • Please indicate if ANYONE in the family has problems with the following:
  • Trouble with anesthesia? * Required
  • Bleeding problems? * Required
  • Other family medical issues? * Required
  • Birth history: Full Term? * Required
  • Immunizations: Up-to-date? * Required
  • Exposure to smoking? * Required
  • Daycare? * Required
  • School? * Required
  • Does your CHILD have any of the following problems?
  • Heart * Required
  • Lungs * Required
  • Stomach/bowels * Required
  • Kidney/Urinary tract * Required
  • Muscles/joints * Required
  • Skin * Required
  • Eye/Vision * Required
  • Diabetes/Thyroid * Required
  • Allergic/Immune * Required
  • Infections * Required
  • Neurological Problems * Required
  • Psychological Problems * Required
  • Weight loss * Required
  • Fevers * Required
  • Any pain on today's visit? * Required
    (If yes, please select score below)
  • (0 = No pain, 10 = Most Severe)
  • Do you have any other children that are seen by Children's ENT Center * Required
  • This field is for validation purposes and should be left unchanged.