New Patients

Welcome to our practice, the Southern New England Ear, Nose, and Throat and Facial Plastic Surgery Group, LLP.  We look forward to meeting you for your appointment


We have 3 forms which need to be completed for new patients.  To expedite your first visit, 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 your browser - or right click and select print .  Alternatively,  select 'save' to download and 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:

  1.  All 3 Forms  downloaded/printed, and completed

               
a)    Patient Identification
                    b)    Patient History
                    c)    HIPAA
                                       
 ALL 3 FORMS

2.  acopy of your insurance card

3.  a listing of your current medications and allergies

4.  your copay (check, cash, or credit card accepted).

5.  a photo ID (driver license, CT. state ID, passport....)

 
 Thank you for your cooperation

COPAYS AND DEDUCTIBLES ARE EXPECTED AT TIME OF VISIT.
 
WE ACCEPT ALL CREDIT CARDS.

THANK YOU
SNEENT MANAGEMENT

 COPAGOS Y DEDUCIBLES SE ESPERA EN EL MOMENTO DE LA VISITA.
ACEPTAMOS TODAS LAS TARJETAS DE CREDITO.

GRACIAS
SNEENT DE GESTION