ENT SPECIALISTS · SURGERY DEPARTMENT - Surgery Interest & Scheduling Questionnaire

ENT SPECIALISTS · SURGERY DEPARTMENT - Surgery Interest & Scheduling Questionnaire

Thank you for your interest in moving forward with surgery. Please complete this questionnaire. Your responses help the Surgery Department begin the scheduling, insurance review, and medical clearance process. Required items are marked.
- Patient & Contact Information
- Who is this questionaire for?
- Patient Name
  
  First NameMiddle NameLast Name
- Parent / Legal Guardian Name
  
  First NameMiddle NameLast Name
- Patient Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Mobile Phone — Patient
  Please enter a valid phone number.Format: (000) 000-0000.
- Mobile Phone - Parent / Guardian
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Address
  example@example.com
- Email Address of Parent / Guardian
  example@example.com
- Date Completed
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Surgery Decision & Scheduling Concerns
- Would you like to move forward with the surgery recommended by your doctor?
- Thank you for your response. Based on your selection, your surgery will not be scheduled at this time. If you would like to discuss your treatment options or have questions, please visit www.floridaentcare.com to request an appointment or call our office to schedule a visit with your doctor. When you are ready to move forward with surgery, you may return and complete this questionnaire.
- Do you have any questions or concerns about the surgery that should be answered before scheduling?
- If yes, please explain
- Insurance Information
- Has your insurance information changed since your last visit?
- Insurance Company
- Member ID Number
- Group Number
- Secondary Insurance Company (if applicable)
- Secondary Member ID Number (if applicable)
- Secondary Group Number (if applicable)
- Hospitalization & Surgery History
- Hospitalized in the past 12 months?
- Hospital Name
- Reason for Stay
- Approx. Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Had surgery in the past 12 months?
- Procedure
- Approx. Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Pediatric Specialist & Condition Information
- Does your child see any pediatric specialist doctors?
- Specialist Name
- Specialty
- Reason for Care
- Do your child have a blood disorder or blood condition that causes them to bleed more easily or makes it difficult to stop bleeding?
- What blood disorder do they have?
- Name of doctor treating this condition:
- Does your child have any other medical condition that may affect surgery or anesthesia?
- If yes, please Explain
- Adult Health & Medication Information
- Does the patient take any blood thinner medication?
- If yes, list blood thinner medication(s)
- Does the patient take any of the following supplements? (check all that apply)
  
  Other
- Do you have a blood disorder or blood condition that causes you to bleed more easily or makes it difficult to stop bleeding?
- What blood disorder do you have?
- Name of doctor treating this condition:
- Is the patient taking a GLP-1 medication for diabetes or weight loss?
- Medication Name
- Date of Last Dose
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Has the patient ever been diagnosed with Sleep Apnea?
- Does the patient currently use a CPAP machine?
- CPAP Provider
- Notes
- Specialist Doctors & Cardio/Pulmonary History
- Does the patient see a heart doctor (cardiologist)?
- Cardiologist Name
- Cardiologist Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Does the patient have any of the following? (check all that apply)
- Does the patient see a lung doctor (pulmonologist)?
- Pulmonologist Name
- Pulmonologist Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Does the patient see any other specialist doctors?
- Other Specialist Name
- Other Specialist - Reason for Care
- Scheduling Information
- When would you like to have surgery?
- Our Surgery Scheduling Team will use text messages as our primary way of communicating with you during the surgery scheduling process. We may send you appointment updates, scheduling information, reminders, forms, or ask for additional information by text message.
- How would you like our surgery team to contact you?
- Acknowledgements & Confirmation
- Type full name to sign
- By selecting this box, I confirm I would like to move forward with surgery scheduling and the authorization process, and that the information provided is accurate. If I am not the patient, I certify I am the patient's parent, legal guardian, or otherwise legally authorized to act on their behalf.
- Todays Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Thank you for your interest.
Should be Empty:

ENT SPECIALISTS · SURGERY DEPARTMENT - Surgery Interest & Scheduling Questionnaire

Patient & Contact Information

Surgery Decision & Scheduling Concerns

Insurance Information

Hospitalization & Surgery History

Pediatric Specialist & Condition Information

Adult Health & Medication Information

Specialist Doctors & Cardio/Pulmonary History

Scheduling Information

Acknowledgements & Confirmation