Thank you for continuing to see our physicians at the Southern New England Ear, Nose, and Throat and Facial Plastic Surgery Group, LLP for your medical needs.
If you have not been seen within the past 12 months, we do need you to complete 3 forms prior to your visit. Also, if there have been any changes (i.e., address, insurance, etc), we need the 3 forms completed.
Please download/print the 3 forms listed below. Fill in the required information in blue or black ink, and bring all 3 forms with you to your visit.
Forms: (please click form to open in IE- or right click and select print . Alternatively, select 'save' to download to save to hard drive folder, and print later.)
Click on individual form below :
1. Patient Identification
2. Patient History
3. HIPAA (Privacy Practices)
ALL 3 FORMS
Fill in the required information legibly in blue or black ink, and bring all 3 forms with you to your visit.
To make your visit as efficient as possible, please remember to bring the following with you:
3. a listing of your current medications and allergies
4. your copay (check, cash, or credit card accepted).
Thank you for your cooperation.
COPAYS AND DEDUCTIBLES ARE EXPECTED AT TIME OF VISIT.
WE ACCEPT ALL CREDIT CARDS.
COPAGOS Y DEDUCIBLES SE ESPERA EN EL MOMENTO DE LA VISITA.
ACEPTAMOS TODAS LAS TARJETAS DE CREDITO.
SNEENT DE GESTION