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Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.This form contains confidential information and is delivered to your doctor through a secure Internet connection.

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Name
Date
Mailing Address
Birth Date:
If completed by someone other than patient;
Please review and check the following complaints you have:

Do you CURRENTLY have any problems in the following areas?

EARS, NOSE, THROAT
CARDIOVASCULAR
ENDOCRINE (Diabetes, Hypothyroid, etc.)

MEDICATIONS

Including eye drops, over the counter medications, vitamins or supplements
How do you wish to pay for today's visit?
(Please Present ALL Insurance Cards)