OHIO EAR INSTITUTE , LLC
PATIENT INFORMAITON-- PLEASE COMPLETE THE ENTIRE FORM
Last Name: : Home Phone: Work Phone:
First Name: : MI: Address:
Age: DOB: Sex: City: State: Zip:
SSN: Cell phone:
Email Address: Allergies:

Marital Status:

Reason for your visit: your visit:

Referring physician: Phone:
Address:
Primary physician: Phone:
Address:
Insurance Information:    Insurance Company Name:
Insurance holder name: Insurance holder SSN:
Insurance holder DOB: Home phone: Work Phone:
Copay Amount: ount: Address: State: Zip Code:
Group #: Policy #: Plan #:
Is this plan through an employer?: Employer's Name:
Secondary Insurance Company: Name of Company:
Insurance holder name: Insurance holder SSN:
Insurance holder DOB: Home phone: Work Phone:
Copay Amount: ount: Address: State: Zip Code:
Group #: Policy #: Plan #:
Is this plan through an employer? through an employer?: Employer's Name: ame:
Guarantor: Person financially responsible to pay account balance after insurance:
Name: Address:
Phone: City: State: Zip Code:
Emergency Contact: Name: Relationship:
Home Phone: Work Phone:
Cancellation/No Show Policy : Because our time is as valuable as yours, if you fail to show up for your scheduled appointment and do not call to cancel, there will be a $50 charge made to your account.
If you schedule and cancel an appointment two consecutive times, you will incur a similar charge of $50. 		Signature:___________________________________Date:____________
(or representative)

Phone Messages:
May we leave a phone message at home?_______
at work? _______
Name of person(s) authorized to speak about patient's results/condition:

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