Alabama ENT Specialists - New Patient Form

ALABAMA EAR, NOSE & THROAT SPECIALISTS, LLC

New Patient Form
Today's Date*

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age*
Patients SS #
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Please enter a valid phone number.
Name of Employer
Employer Phone
Employer Email
example@example.com
Marital Status

SingleMarriedDivorcedWidowed
Parent or Guardians Name (for minors)
Guardian DOB
Guardian SSN
Guardian Relationship
Referring Doctor (First & Last Name)
Primary Doctor (First & Last Name)
Is this visit a result of accident/injury?

YesNo
If "Yes", brief description of accident and when & where it occured?
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address

Pharmacy Street Address

Street Address Line 2

Pharmacy City
How did you find us?

PhysicianHospitalFriendWebsiteAdvertisementOther
Insurance Information
Please have insurance card & driver's license available at time of appointment. It is necessary to have accurate information to file your claim. If information provided below is incorrect or incomplete you will be financially responsible for all charges rendered.
Primary Insurance Company
Employer
Relationship of Patient to Insured:

SelfSpouseChildOther
Policy/ID #
Group #
Policy Holder's Name
Policy Holder's DOB
Policy Holder's SS #
Secondary Insurance Company
Employer
Relationship of Patient to Insured:

SelfSpouseChildOther
Policy/ID#
Group #
Policy Holder's Name
Policy Holder's DOB
Policy Holder's SS #
PATIENT MEDICAL HISTORY
Patient's Name
Patient's DOB
Reason for today's visit
List your medications and dosage
Drug allergies
Prior Surgeries
Prior Radiation

YesNo
Prior Chemotherapy

YesNo

Patient History

	Past	Current
Allergic Rhinitis
Anxiety
Asthma
Heart Condition
Lung Disease
Diabetes
Hearing Loss
Heartburn/Reflux
High Blood Pressure
Sleep Apnea/Snoring
Kidney Failure
Sinusitis
Stroke
Smoking
Anemia
Depression
Heart Attack
Hypothyroidism
Migraine
Cancer (type)
Other

Cancer (type)
Other

Family History

	Mother	Father	Brother	Sister
Allergic Rhinitis
Anxiety
Asthma
Heart Condition
Lung Disease
Diabetes
Hearing Loss
Heartburn/Reflux
High Blood Pressure
Sleep Apnea/Snoring
Kidney Failure
Sinusitis
Stroke
Smoking
Anemia
Depression
Heart Attack
Hypothyroidism
Migraine
Cancer (type)
Other

Cancer (type)
Other
PATIENT HISTORY
Do you use: Cigarette/Pipe/Cigar/Chew?

YesNo
How much?
For how long?
Are you still using?

YesNo
Former user?

YesNo
When did you quit?
Do you consume alcohol?

YesNo
How much?
How often?
Have you ever used illegal drugs or IV drugs?

YesNo
What drugs?
Please circle the appropriate boxes if you are experiencing any of the following symptoms:
General

Fever/ChillsBody AchesUnexplained Weight Loss
Eyes

WateryItchyBlurringDouble Vision
Ear, Nose, Throat

Ear PainHearing Loss/RingingDizzyStuffy NoseRunny NoseHoarsenessSore ThroatTrouble Swallowing
Cardiovascular

Chest PainPalpitationsFainting
Respiratory

CoughShortness of BreathWheezing
Gastrointestinal

NauseaVomitingDiarrhea
Musculoskeletal

Joint PainJoint SwellingMuscle Cramps
Skin

EczemaRashesSuspicious Lesions
Neurologic

ParalysisNumbnessSeizures
Hemelymphatic

Abnormal BruisingAbnormal BleedingEnlarged Lymph Nodes
Allergic/Immune

Nasal AllergiesAllergic DermatitisRecurring Infections
Patient's Signature*

Clear
Patient's DOB*

MonthDayYear
Date
Date*

MonthDayYear
Date
ASSIGNMENT OF BENEFIT AGREEMENT
Parent/Legal Guardian (Print)*
Signature*

Clear
Date*

MonthDayYear
Date
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
You have been given the Notice of Privacy Practices for Alabama Ear, Nose & Throat Specialists, LLC (AENTS) and its Physicians. This Notice describes your legal rights regarding your health information and will inform you of the legal duties and privacy practices of AENTS with respect to health information created for services generated by AENTS. If you receive services by your physician or other health care providers at a different location, you may want to ask about that office or clinic's health information privacy policies and notices because they could be different.

Your name and signature below indicates that you have been provided with a copy of this Notice of Privacy Practices.

If you have a question regarding any of the information set forth in this Notice of Privacy Practices, please do not hesitate to call our Practice Administrator at (205) 523-9300.
Patient Name*
Date*

MonthDayYear
Date
Signature of Patient or Responsible Party*

Clear
PERSONAL HEALTH INFORMATION CONTACTS:

I authorize ALENTS and medical staff to discuss my healthcare information (which may include history, diagnosis, labs, test, results, treatments and other health information) with the contacts listed below.
Contact Name
Relationship to Patient
Contact Info
Contact Name
Relationship to Patient
Contact Info
Contact Name
Relationship to Patient
Contact Info
EMERGENCY CONTACT ONLY:
Emergency Contact Name
Relationship to Patient
Emergency Contact Phone
At which phone numbers would you like to recieve calls about appointment, financial, or medical condition information? (Check all that apply)

Home phoneCell phoneWork phoneOther
Voice Mail: May appointment, financial, or medical information be left on your answering machine or voice mail?

YesNo
Email: When responding to Email, may we include appointment, financial, or medical condition information?

YesNo
Patient Signature

Clear
Thank you for choosing Alabama Ear, Nose & Throat Specialists. In order to track Meaningful Use of our Electronic Medical Record, we are required to maintain the information below as part of your personal medical record. As with all of your medical information, this will be maintained CONFIDENTIALLY.
Patient Name
Email Address
example@example.com
Primary Language (Check One)

EnglishSpanishIndian (Includes Hindi & Tamil)RussianOther
Race (Check One)

American Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderBlack or African AmericanWhiteHispanicOther raceUnreported/prefer not to answer
Ethnicity (Check One)

Hispanic or LatinoNot Hispanic or LatinoPrefer Not to Answer
dlm_client
Should be Empty:

ALABAMA EAR, NOSE & THROAT SPECIALISTS, LLC

Insurance Information

PATIENT MEDICAL HISTORY

PATIENT HISTORY

ASSIGNMENT OF BENEFIT AGREEMENT

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

PERSONAL HEALTH INFORMATION CONTACTS:

EMERGENCY CONTACT ONLY: