New Patient Form

Virginia Ear Nose & Throat Associates
New Patient Form

Please fill out the following form carefully, and submit it to us online prior to your first appointment.

This is a secure form. Your information will remain protected and encrypted. Click the "lock" icon to view our security certificate. If you prefer to print the form and bring it to us in person, click here. You may also view our privacy policy.

Patient Information Full Name: Date of Birth: Sex:

Address: Unit #: City: State: Zip:

Home Phone: Work Phone: Cell Phone:

SSN: Referring Doctor: Primary Doctor:

Email: Employer:

Employer Address: City: State: Zip:

Emergency Information Emergency Contact: Phone: Relationship:

Guarantor Information (Person Responsible for Billing) Same as Patient

Full Name: Date of Birth: Sex:

Address: Unit #: City: State: Zip:

Home Phone: Work Phone: Cell Phone:

SSN: Employer:

Employer Address: City: State: Zip:

Insurance Information Primary Insurance: Policy ID: Group#:

Group Name: CoPay:

Insurer Address: City: State: Zip:

Primary Person on Insurance: Date of Birth: Sex:

SSN:

Secondary Insurance: Policy ID: Group#:

Group Name: CoPay:

Insurer Address: City: State: Zip:

Primary Person on Insurance:

Date of Birth: Sex: SSN:

Patient History Full Name: Age: Date of Birth:

Referring Physician:

Reason for your visit:

Medication Allergies: None

Family Medical History - Does anyone in your family have the following:

Allergies
Bleeding Trouble
Heart Disease
Anesthesia Difficulty
Diabetes
Throat Cancer
Asthma
Hearing Loss
Unknown/Adopted

Medical & Surgical History: (list all medical problems & previous surgeries) None

Social History: None

Cigarettes:	Packs Per Day Year Began Year Quit
Other Tobacco:	Amount Per Day Year Began Year Quit
Caffeine:	Drinks Per Day
Alcohol:	Drinks Per Week
Street Drugs:	Explain

Current Medications: None

Review of Systems - Do any of the following items pertain to you?

General
Prematurity
Late Development
Eating Disorders
Fever
Anorexia
Fatigue
Significant Weight Change

Skin
Skin Cancer
Change in Wart/Mole

Neck
Neck Pain
Swollen Glands
Asthma

Respiratory
Chronic Cough
Sleep Apnea
Snoring Cardiovascular
Heart Murmur
Heart Defects
Irregular Heartbeat
Shortness of Breath
Hypertension
Chest Pain
Leg Pain and/or Swelling

Gastrointestinal
Heartburn, Reflux, Regurgitation
Vomiting
Difficulty Swallowing

Female
Pregnant
Absence of Menstruation Neurological
Meningitis
Facial Pain
Seizures
Dizziness
Headaches
Auras
Stroke
Fainting

Endocrine
Diabetes
Failure to grow
Thyroid Problems

Hematology
Abnormal Bleeding
Anemia
Blood Clots
Nose Bleeds

Pharmacy of Choice:

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