Patient Registration Form

Dr. Charles Mann • Dr. Richard Jones • Dr. Jared Spector

Mann ENT Clinic
601 Keisler Drive, Suite 200
Cary, NC 27511

919-859-4744

Please review our FINANCIAL POLICY prior to filling out the Patient Registration Form.

Please fill in the following form, PRINT IT out and BRING IT with you to your office visit in order to save time during your appointment.

First Name:     MI:    Last Name:

Address:

City:    State:     Zip Code:-

Home Phone:                 Work Phone:

Date of Birth: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005             Age: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105   

  Sex: Male Female

Marital Status:  Married Single       Social Security #:     

Driver's License #:

Occupation:  Employer:         Race: White/Caucasion African_American Asian Hispanic Native American Other

Emergency Contact:         Relationship:

Home Phone:         Work Phone: 

Referred By:    Primary Care Physician:

If Minor, Parent or Guardian Name:

Person Responsible for Bill:

Address:

Home Phone:          Work Phone: 

INSURANCE INFORMATION

Name of Insurance Company: 

Address To Mail Claims:

Insurance Company Phone:

Name of Policy Holder:

Policy Holder's ID:

Group #:

Policy Holder's DOB:  Social Security #:

Payment is expected at the time of service. Method of payment you will be using:

Cash Check Visa/Mastercard

I hereby authorize my insurance benefits to be paid directly to Mann ENT. I also authorize Mann ENT to release information acquired in the course of my examination. I agree that I am responsible for payment of all uncovered services. I have read, understood and agree to the Financial Policy at the top of the page. (Note: We will need your signature when you come in for your visit.)

Check this box if you agree to the above statement.

PERSONAL & MEDICAL HISTORY INFORMATION

(Please Limit Responses to the Space Provided)

REASON FOR VISIT (One sentence please):

PLEASE SUCCINCTLY DESCRIBE THE ABOVE PROBLEM,

INCLUDING DATE OF ONSET, PERSISTENCE, SEVERITY, QUALITY,

INCITING FACTORS, PAST TREATMENTS AND STRONG ASSOCIATIONS.

# of Brothers:         # of Sisters:         # of Children:

Family History (Diabetes, Heart Disease, Hearing Loss etc.):

Are you taking medication daily: Yes No If yes, List:

List any allergies to medications and the reaction you have:

Have you ever used tobacco: Yes No     If yes, Dates:
Average Daily Amount

Daily Alcohol Intake:

Daily Caffeine (coffee, tea, soft drinks, chocolate) intake:

Prior hospitalizations: No Yes Please list (include reason, location & date):

Prior surgery: No Yes    Please list (include reason, location and date):

Problems with surgery: No Yes    Problems with anesthesia: No Yes

Prior Allergy testing/treatment: No Yes     If yes, list dates, type of treatment & results:

Do you wish allergy testing in our office? No Yes

Please mark all of the following that apply:

Snoring/Sleep Apnea     |     Nasal Obstruction     |    Sinus Infections    |      Facial Cosmetic Concerns

 Asthma          bronchitis        pneumonia        HIV, AIDS              Hepatitis

Back Problems     |    numbness in arms/legs    |     Blood Transfusions in past 10 years

Excessive bleeding when cut     |    Psychiatric Problems (past/current)         

Heart Attack     |    Angina    |    Chest pain    |    Neurological disease (faint, convulsion)

Hepatitis or Yellow Jaundice    |     Kidney disease, stones, cystitis    |     Slow Healing of wounds

Keloids or excessive scarring    |     Hives or allergic skin reactions     |    Skin Cancer

TB or Syphilis     |     Heart Murmur     |    Hearing Loss     |    Acne       

Blood Pressure Problems     |    Cardiac Pacemaker    |      Cancer     |     Diabetes

Thyroid Disease or Goiter     |    Anemia or low blood    |     Frequent headaches

Arthritis     |     Ulcers    |    Bruising easily    |      Hay fever/Allergies (Seasonal)

Allergies to tapes, soaps, solutions     |    Allergies to anesthetics (Novocaine)

Take Aspirin (Bufferin, BC, Anacin)    |     Other?  

Weight (in pounds): 

Please list below any family members that our doctors have treated in the recent past, with diagnoses or operations performed:

List below any other conditions/concerns you believe would be relevant to your office visit:

Your E-mail Address:

Your Pharamacy Name:     Pharmacy Phone No.:

Do you want Mann ENT Clinic to send updates to your primary care physician? YES NO

Your date of appointment: 

Please review our FINANCIAL POLICY prior to your office visit.

After filling in this form, PRINT IT out and BRING IT with you to your office visit in order to save time during your appointment.

Thank You.

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