ent specialists
720 North 129th Street
Omaha, NE 68154

Monday - Friday: 8am-5pm


Phone:402.397.0670
Fax:402.397.0713
After Hours:402.354.2754

These forms are available to help speed up the process of registering new patients. Please arrive 15 minutes early for your appointment in order to complete the registration process.

Submitting your information electronically by completing the fields shown below helps to speed up the registration process! You only need to arrive 10 minutes early if you complete the fields below and submit electronically.

IF SUBMITTING YOUR INFORMATION ELECTRONICALLY, ALL FIELDS WITH AN ASTERISK MUST BE COMPLETED OR YOUR FORM WILL NOT BE PROCESSED.  PLEASE MAKE SURE YOU RECEIVE A THANK YOU/CONFIRMATION PAGE WHEN YOU CLICK SUBMIT!

Please bring the following information to your first visit:
  • Health insurance card
  • Driver’s license/photo ID
  • List of all medications you are taking
  • List of questions/concerns
  • Copies of records from doctors related to your sinuses/nose/allergies/lungs
  • CT imaging and report
  • Completed registration forms (see below)

YOU MAY BE ASKED FOR YOUR PHOTO ID AND INSURANCE CARD AT EACH VISIT. ALL CO-PAYMENTS ARE DUE AT THE TIME OF YOUR APPOINTMENT.

If you recently have noticed decreased hearing, save a co-pay and schedule a hearing test at the same time as your appointment with your ENT physician.  Please call our office before you arrive for your appointment if you would like to schedule a hearing test.

Downloadable Forms:


Financial Agreement (please download form, complete, and bring with you to appointment)

Please complete the following information and submit electronically. If you choose to not submit the information below electronically, you may download the Patient Information and Medical History Forms by clicking the following links:
Patient Information (only download, print and complete if you do not complete the information below and submit electronically)
Medical History (only download, print and complete if you do not complete the information below and submit electronically)


To view ENT Specialists, PC, Notice of Privacy Practices, please click HERE

PATIENT INFORMATION

*Last Name:
*First Name:
Middle Initial:
*Age:
*Birth Date:
*Sex:
Social Security Number:
*Marital Status:
*Race:


*Ethnicity:
*Language Preference:
*Street Address:
*City:
*State:
*Zip:
*Home Phone (w/area code):
*Cell Phone:
E-mail Address:
Mother's name (if patient is a minor):
Mother's cell phone:
Father's name (if patient is a minor):
Father's cell phone:
*Employer (if child, list employer for parent/guardian:
Work Phone:
*Emergency Contact (Name):
*(Relationship):
*Emergency Contact Phone:

Please indicate your preference for appointment reminders (check all that apply):

*Primary Physician:
Referring Physician:

*Name of Pharmacy:
*Address of Pharmacy:

*Please indicate your insurance carrier (check all that apply if more than one policy). Important Note: You should ALWAYS bring your insurance card to your appointment; co-pays DUE PRIOR TO BEING SEEN:




Other (if not listed above):
Guarantor: Responsible Person for Paying Bill
GUARANTOR: Person responsible for paying for services(Please put insurance holder here, if Medicaid list parent):

(Primary Policy)
*Primary Policy Holder (name of person):
*Relationship (Primary policy holder's relationship to you: "self, spouse, parent, etc"):
Primary Policy Holder's Social Security Number:
*Primary Policy Holder's Birth Date:
(Secondary Policy)
Secondary Policy Holder's Name:
Secondary Policy Holder's Relationship to you (ie "Self, Spouse, Parent, etc"):
Secondary Policy Holder's Social Security Number:
Secondary Policy Holder's Birth Date:

How did you hear about ENT Specialists?:


Other :
Referring Physician:

Parents/Guardians must complete this next section for dependents younger than 19 years of age:
By checking this box and signing my name below, I state that in presenting my child/dependent for diagnosis and treatment, I hereby voluntarily consent to the rendering of care, including diagnostic procedures, outpatient procedures, and medical treatment, by authorized physicians and staff of ENT Specialists, PC. No guarantees have been made to me regarding the result of treatments or examinations by staff of ENT Specialists, PC. I consent to the use and disclosure of protected health information about my dependent for treatment, payment and healthcare operations. I guarantee payment to ENT Specialists, PC of all charges for services provided to my dependent. I understand I am personally responsible for all charges not covered by insurance.
Parent/Guardian Signature:
Date:
Open the calendar popup.

PATIENT MEDICAL HISTORY
*Reason for today's visit:
*Current illnesses or health conditions (Please list. State "none" if no current illnesses):
*Current medications, including over the counter medications/vitamins or supplements (Please list with dosing, if known. State "none" if no medications):
*Surgeries (Please list with approximate dates. State "none" if no past surgeries):
Allergies (please list):
*Tobacco Use:


If former tobacco user, please list quit date:
Open the calendar popup.
*Bleeding problems?:
If yes to bleeding problems, please explain:
REVIEW OF SYSTEMS.
Please check all CURRENT symptoms
*General:


*Eyes:


*Ears:


*Nose:
*Throat:
*Cardiovascular:
*Respiratory:
*Gastrointestinal:
*Musculoskeletal:
*Skin:
*Neurologic:
*Psychiatric:
Please list if you checked "Other Psychiatric":
*Endocrine:

MISCELLANEOUS
*Would you like to schedule a hearing test with an audiologist in addition to your appointment with your ENT Specialists physician?:
*Do you need an interpreter?:
If you do need an interpreter, what language/dialect:
*Please check to indicate that you understand your co-pay is due PRIOR to your appointment (specialist co-pay listed on your insurance card):
*Please check to indicate that you understand you may be asked for your insurance card at every visit:
*Please check to indicate you understand you will be expected to pay amount due on day of service if you are self-pay or your insurance is pending:
*Please check to indicate that you understand that if you are scheduled for surgery, you must pay ENT Specialists, PC, the dollar amount of your unfulfilled insurance deductible 7 days prior to surgery:
When you click "Submit," you should receive a confirmation/thank you page. If you do not, you likely need to give more information for one question (should be noted in red). If you do not receive a confirmation page, your form will not be processed, and you will have to complete paperwork when you arrive at clinic!
 

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