New Patient Form

1 ©2017 Milton Hall Surgical Associates, LLC. All Rights Reserved.

Copying of this document is only permitted by express permission from Milton Hall Surgical Associates, LLC.

Patient Name: ______________________ (Last, First, Middle Initial) Sex: (M/F)

Date of Birth: ______/______/_______ SSN: ______-______-__________

Address: ___________________________ Zip Code: __________ City: _____________ State: _____

Home Phone: (____)_____-______Cell Phone: (_____)_____-______ Work Phone: (____)_____-______

Do you give the ENT Institute permission to text your mobile device? YES or NO

E-mail Address: _________________________________ Preferred Contact Method:_____________

Primary Language: _________________ Race: __________ Ethnicity: __________________________

Marital Status(Married/Single/Other): _________________________

Employer: ______________________________________ Phone Number: (______)_______-________

Occupation: _______________________________________ Industry: __________________________

Are you the Guarantor/Responsible Party? YES or NO

IF YOUR ANSWER WAS NO, PLEASE PROVIDE:

Guarantor Name: _________________________________________ Date of Birth: _____/______/_____

(Last, First, Middle Initial)

Relationship to Patient: _______________ Address: __________________________________________

Emergency Contact Name: ________________________________

Relationship:__________________________

Home Phone: (______)______-_________ Cell Phone: (______)_______-________

Next of Kin Name: ______________________________ Relationship to Patient: ___________________

Contact Number: (______)_______-________

How did you hear about us? _______________________________________

Do you have a Primary Care Physician? YES or NO

If yes, who is your Primary Care Physician? __________________________

Do you consent to receive automated phone calls from our practice on your mobile device? YES or

NO

Is your mailing address the same as your street address? YES or NO

If your answer was no, please indicate your mailing address:

_____________________________________________________________________________________

INSURANCE INFORMATION

Primary Insurance Policy

Insurance Company: _______________________________ HMO PPO POS (circle one)

Insured’s Name (Policyholder): _____________________________________

New Patient Form

2 ©2017 Milton Hall Surgical Associates, LLC. All Rights Reserved.

Copying of this document is only permitted by express permission from Milton Hall Surgical Associates, LLC.

Insured’s SSN: ______-______-______ Insured’s Sex: __________

Insured’s Date of Birth:______/______/______

Insured’s Employer: _______________________________

Secondary Insurance Policy

Insurance Company: _______________________________ HMO PPO POS (circle one)

Insured’s Name (Policyholder): _____________________________________

Insured’s SSN: ______-______-______ Insured’s Sex:__________

Insured’s Date of Birth:______/______/______ Insured’s Employer:

________________________________________

Co-pays, deductibles and any other patient responsibility fee are due when services are rendered. If you

have any questions about fees, please check with us prior to being seen. I understand that insurance will

be filed by your office as a courtesy and does not constitute a contract between the physician and

insurance company for payment of services.

PATIENT SIGNATURE / AUTHORIZED GUARDIAN :______________________________________

DATE_______/_______/_______

PRINT PATIENT NAME: _____________________________________________