PLEASE FILL OUT ALL 3 FORMS FOR ALL NEW PATIENTS 

Secure Online Forms

• Patient Forms - English
• Patient Forms - Spanish

Printable Forms: English

• NEW PATIENT INFORMATION 
• HISTORY FORM
• HIPPA AUTHORIZATION

Printable Forms: Spanish

• NEW PATIENT INFORMATION
• HISTORY FORM
• HIPPA AUTHORIZATION

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We would like to take this opportunity to welcome you to our practice, and thank you for choosing Florida ENT Adult & Pediatric, Inc. The following are office polices that should be reviewed prior to your appointment. For your convenience we have included new patient forms above.

• To provide excellent quality care, we request new patients bring current medication list whether they are prescribed or over the counter, any medical records from their primary care physician that pertains to their ear, nose or throat problem you are seeing the specialist for. Please bring any recent X-ray, CT scan, or MRI films which you may feel are important for your visit.
• If this appointment is for minor, a parent or legal guardian will need to accompany them and be present for every visit, or parent or legal guardian must sign child care consent with a copy of their photo ID. 
• Please confirm we are providers for your insurance plan. Our staff will do their best to let you know if our physician is considered out-of-network for your plan. However, it is your responsibility to know your insurance plan. 
• Please bring your current insurance card to your appointment along with a picture ID of the policy holder. We will file for all HMO and PPO insurance plans we participate with and will accept assignment for Medicare. If our staff cannot verify insurance coverage at the time of your appointment, the visit will be considered self-pay and full payment will be expected at the time of service. 
• If your health insurance requires a referral from a primary care physician, your appointment will be cancelled if we have not received authorization by your appointment time. 
• At the time of your office visit or at a follow up visit our physician may require additional tests and/or diagnostic procedures in order to care for you. Depending on your insurance coverage, these procedures may require an additional co-payment or deductible, or referrals/authorizations.

Additional Forms:

• Release of Medical Records
• Child Care Consent
• Physician/Patient Disclosure Forms
• VNG Instructions
• Instrucciones De VNG