Skip to main content
New Patient Registration

New Patient Registration

Website Registration

Choose Your Preferred Location

Patient Information

Sex
Marital Status
Race
Ethnicity
Preferred Language

Person Responsible for Patient Account

Check if Self

In Case of Emergency Contact

1. Insurance Information

2. Insurance Information

Pharmacy Information

General Consent For Treatment

As the patient, you have the right to be informed about your conditions and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify appropriate treatment and/or procedure for any identified condition(s).

I request and authorize medical care as my provider, his assistant or designees (collectively called “the providers”) may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care. I authorize my provider(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my provider(s) and that other personnel render care and services to me (the patient) according to the provider(s) instructions.

I understand that I have the right and the opportunity to discuss alternative plans of treatment with my provider and to ask and have answered to my satisfaction any questions or concerns.

(initial)

I HAVE READ OR HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAD THESE QUESTIONS ADDRESSED.

Consent of Legal Guardian, Patient Advocate or Nearest Relative if patient is unable to sign
Consent Caregiver if patient is unable to sign
Time

Call now to speak to a hearing professional to learn more or to schedule your appointment to see a board certified ENT physician

(931) 647-1255 Clarksville
(731) 540-4522 Paris