Patient Registration Form

New York Center for ENT, Sinus and Allergy LLP

NEW PATIENT INFORMATION

Please print this form, fill it out, and bring it with you to our office. Thank you.

First Name____________________________
Last Name____________________________
Address____________________________Apt. #______
Zip Code_______ Date Of Birth____________
Home Phone # (______) _______ -__________
Cell Phone    # (______) _______ -__________
Work Phone # (______) _______ -__________
Marital Status_______________ Gender    M    F
Social Security # _________- ______- __________
Closest Relative Phone # (_______) ____-______

Primary Insurance Company _________________________________________
Identification # _____________________________
Group # (If Any)________________________
Name Of Person On Card__________________
Relationship To Patient__________________

Secondary Insurance Company_________________________________________
Identification #_______________________________
Group # (If Any)________________________
Name Of Person On Card___________________
Relationship To Patient__________________

 Referring Doctor (If None, Primary Care Doctor & His/Her Phone Number)
Physician______________________________________

Past Medical History Of:
Sinusitis_____ Hay Fever_____
Diminished Hearing_____ Diabetes_____
Chronic Cough ____ Dizziness _____
Difficulty Swallowing____ Wheezing_____
Frequent Headaches____ Tumor, Cyst Or Cancer______
High Blood Pressure _____ Difficulty Urinating ______
Heart Disease or Murmur_______

Previous Surgery (Please Indicate Type And Year (S))
______________________________________________________





Drug or food allergies_____________________________
Medications you are taking____________________________


I Authorize The Release Of Any Medical Or Other Information Necessary To Process My Medical Claims. I Also Authorize Payment Of Medical Benefits To The Provider Of Service. I am Responsible For Any Payments Not Made By My Insurance Carrier, For Example: Deductibles, Co-Payments, Etc.



Signature_____________________
Date________________________