Lafayette ENT: (765) 477-7436
Audiodiagnostics II: (765) 477-7016

For new patients, please print out and complete all of these forms; and, bring them to your first visit. Also, remember to bring your current insurance card(s). If you are unable to print these forms in advance, please make sure to arrive 15 minutes prior to your scheduled appointment so that you may fill them out in the office. Thank you.

INSURANCE FORM 06 - Web

MEDICATION LIST

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGE FORM

PATIENT MEDICAL SURGICAL HISTORY

PATIENT REGISTRATION

PRIVACY NOTICE

 

Helpful Links:

Audiodiagnostics II, Inc.
Sagamore Surgical Services Center
American Academy of Otolaryngology
American Academy of Otolaryngic Allergy
American Rhinologic Society
American Head & Neck Society