ENT Specialists

Intake Paperwork - Patient Information

Ear, Nose & Throat Specialists serving Indianapolis, Carmel, Avon and all of Central Indiana

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The information you provide will be encrypted before transmitting over the Internet. Note the URL (https://forms.northsideent.com) and the lock icon in your browsers status bar.

 

Please fill out the following information if you are a NEW Patient or if your information has changed since your last visit.

 

PATIENT INFORMATION

First Name:  Middle Initial: Last Name:

Sex: Date of Birth: Age:
Age in Months [Children under 2 yrs old] Social Security #:

Patient's Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Employer: Work Phone:

Marital Status: Email Address:

 

BILLING INFORMATION (Responsible for Bill)

Check this box if the Billing Info is the same as above

First Name:   Middle Initial: Last Name:

Social Security #: Relationship to Patient:

Home Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Employer: Work Phone:

 

INSURANCE INFORMATION

Primary Insurance:

ID Number: Group Number:

Member's (Full) Name: Social Security #:

Date of Birth:

Employer: Relationship to Patient:

 

Secondary Insurance:

ID Number: Group Number:

Member's (Full) Name: Social Security #:

Date of Birth:

Employer: Relationship to Patient:

 

EMERGENCY CONTACT INFORMATION

Emergency Contact:

Home Phone: Cell Phone: Work Phone:

Relationship to Patient:

Known Drug Allergies:

 

REFERRING PHYSICIAN

Referring Physician: Phone:

Family Physician: Phone:

Has the patient been seen previously by any of our physician's?: Yes No

Is the reason for your visit due to an accident/worker's compensation? Yes No

If yes, please state the date of injury

 



 

Schedule an Appointment

To schedule or change an appointment with one of our physicians, please contact one of our scheduling specialists at (317) 844-5656 or 1-800-556-5456.

If you would like to have a scheduler call you to make or change your appointment, please click here to email us and someone will be in touch with you.

Northside ENT Locations

Main Office

12065 Old Meridian Street
Suite 205
Carmel, IN 46032

Avon

1115 Ronald Reagan Parkway
Physician Office Ctr I of Clarion Hospital W
Suite 254
Avon, IN 46123

Contact Phone Numbers

Telephone Numbers
(317) 844-5656
(800) 556-5456

Business Office
(317) 844-6403

Fax Number
(317) 575-3789