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Ear, Nose & Throat Associates

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New Patient Forms

These three forms need to be filled in by all new patients. For your convenience, we offer electronic versions for you to complete at home before your appointment. You may fill them in using your computer, and email them back to us 48 business hours prior to your appointment. Or, you may print them, complete them and bring them to your appointment. If you prefer, please arrive 15 minutes before your appointment, and complete these forms in our waiting room.

Acknowledgement of Receipt of Notices of Privacy Practices (One page)

Read and/or print our Privacy Practices

Patient Demographics and Insurance Information Form (One page)

Medical History Questionnaire (Three pages)

A few tips if you complete the new patient forms electronically:
  • You may use the tab button to move to the next data entry field.
  • Enter all ten of the digits of phone numbers without spaces, or dashes (i.e., 6503691619).
  • Please do not add or delete any text to the email generated by the "submit by email" button - just send as is.
  • If you electronically fill in these forms, signature data entry fields will be blocked. Completed forms will be printed and ready for you to review, sign and date when you arrive for your appointment, so please arrive five minutes early.
  • For those of you who have not yet used a pull-down calendar, here is a short slide show with instructions (push F5 to restart the slides):
ENT Home Patient Privacy Contact Us Site Map

100 South Ellsworth Avenue, Suite 308, San Mateo CA 94401
tel 650/344 6896    fax 650/344 2794

805 Veterans Boulevard, Suite 115, Redwood City CA 94063
tel 650/369 1619    fax 650/474 2997
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