PATIENT FORMS

All new patients, and established patients who have not been seen in a year, need to complete a Registration Form, a Medical History Form and a Review of Systems Form. Completing your forms and sending them to us prior to your appointment helps us to lessen your wait time in the office.

A Review of Systems Form must be completed for every visit for both new and established patients.

Click on the download icon and choose to either download or open the form on your computer.

Print the form using your printer and fill out the forms.

Bring the completed form(s) into the office at the time of your appointment fax the forms to ENT Partners of Texas at (972) 695-8796 or email them securely to mytexasent@myupdox.com.

You can also click the links next to the forms to submit easily and securely online.

Forms required for all new adult patients in one packet. Please complete all blanks that are applicable in the form. All information is vital to record keeping and verification of insurance benefits. Your signature will be obtained when you sign in. Please indicate your primary care doctor and the doctor or person who referred you. Required for new adult patients or if not seen in the office in 12 months.

Click here to complete and submit the Patient Packet form securely online.
Click here to complete and submit the Pacquete del Paciente form securely online.
Click here to complete and submit the Child Patient Packet form securely online.

Adult Registration (Use for anyone 18 yrs and older). Form required for all new adult patients. All established patients must complete this form once every year. Please complete all blanks that are applicable in the form. All information is vital to record keeping and verification of insurance benefits. Your signature will be obtained when you sign in. Please indicate your primary care doctor and the doctor or person who referred you. Required for new adult patients or if not seen in office in 12 months.

Click here to complete and submit the Adult – New Patient Registration form securely online.
Click here to complete and submit the Registracion de Paciente form securely online.

Child Registration (Use for anyone 0-17 yrs old). To be filled out by the parent or legal guardian of the child. Form required for all new pediatric patients. All established pediatric patients must complete this form once every year. Please fill in all blanks that are applicable in the form. All information is vital to record keeping and verification of insurance benefits. Your signature will be obtained when you sign in. The parent or legal guardian must accompany the child to all office visits or a letter of consent naming the person allowed to have the child treated must be sent with the child. Required for new child patients or if not seen in office in 12 months.

Click here to complete and submit the Child – New Patient Registration form securely online.
Click here to complete and submit the Registracion de Paciente Menor (Espanol) form securely online.

Medical History Form (For ALL Patients). Please complete all blanks that are applicable in the form. All information is vital to record keeping and medical history.

Click here to complete and submit the Medical History form securely online.
Click here to complete and submit the El Historial Medico (Espanol) form securely online.

Review of Systems. Form required for all patients, new and established, adult and pediatric, at every visit.

Click here to complete and submit the Adult – Review of Systems form securely online.
Click here to complete and submit the Pediatric – Review of Systems form securely online.
Click here to complete and submit the Revision de Sistemas – Adulto (Espanol) form securely online.
Click here to complete and submit the Revision de Sistemas – Pediatrico (Espanol) form securely online.

Eppworth Sleepiness Scale. If you suffer from any sleeping problems, please complete the Eppworth Sleepiness Scale and bring it to your visit. Click the form below to download and print.

Epworth Sleepiness Scale

Authorization For Treatment of Minors (Use for anyone 0-17 yrs old). If your child needs medical, dental or hospital services, a parent must give permission. It’s the law. A child may be treated without parental consent when a physician determines a true emergency exists. That means the doctor determines the child needs immediate medical care and that an attempt to obtain parental consent would result in a delay which would increase the risk to the child’s life or health. Except in a true emergency, care may be ordinarily rendered to a child only with the consent of the parent or legal guardian. Sometimes a child may need unexpected care which is not, however, a true emergency. In such cases, making an effort to contact a parent for permission can delay treatment and create unnecessary anxious moments for the child. Fill out this form, give it to the adult(s) you have named to act on your behalf. If your child needs unexpected medical treatment, the responsible adult(s) should present this document to the appropriate person- physician, dentist or hospital representative.

Authorization for Treatment of Minors