Allergy Shots | Mondays 8:30AM-11:30AM and 1PM-4PM | Tuesdays 1PM-4PM | Wednesdays 7:30AM-11:30AM and 1PM-4PM

PATIENT FORMS

All new patients need to complete a Registration Form, a Medical History Form, a Patient Portal Consent Form and a Review of Systems.

All established patients must complete a Registration Form, a Medical History Form, and a Review of Systems once every year. A Review of Systems must be completed for every visit for both new and established patients. Completing your forms and sending them to us prior to your appointment helps us to lessen your wait time in the office.

FORM PROCESSING INSTRUCTIONS

  1. Click on the download icon and choose to either download or open the form on your computer.
  2. Print the form using your printer and fill out the forms.
  3. 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.

REQUIRED PATIENT FORMS

Adult Registration (Use for anyone 18 yrs and older). 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. Click to download form Required for new adult patients or if not seen in office in 12 months.

Adult – New Patient Registration Form
Registracion de Paciente (Espanol)

Child Registration (Use for anyone 0-17 yrs old). To be filled out by the parent or legal guardian of the child. 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. click to download form Required for new child patients or if not seen in office in 12 months.

Child – New Patient Registration Form
Registracion de Paciente Menor (Espanol)

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

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 to download this required form.

Medical History Forms
El Historial Medico (Espanol)

Patient Portal Consent Form (For ALL Patients). To better serve our patients, this office has established an email/portal for some forms of communication. You will receive an email with your login and password for the portal once your release has been signed and scanned into your file. You will then have access to a variety of functions. For more information, you can visit our Patient Portal page.

Patient Portal Consent Form

Review of Systems (FOR ESTABLISHED PATIENTS ONLY). In an effort to shorten waiting times in our office we would appreciate you completing the Review of Systems for established patients (adult and children). Please print and bring with you at your next appointment. Thanks you for your cooperation. Click to download the appropriate form.

Adult – Review of Systems
Pediatric – Review of Systems
Revision de Sistemas – Adulto (Espanol)
Revision de Sistemas – Pediatrico (Espanol)

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

To better serve our patients, ENT Partners of Texas (formerly Irving-Coppell ENT) has established a portal for HIPAA and private medical related forms of communication.

PATIENT PORTAL

400 West LBJ FreewaySuite 360
Irving, Texas 75063
(972) 402-8404 Office
(972) 695-8796 Fax
mytexasent@myupdox.com Email/Fax

OFFICE HOURS

Mon – Thurs: 7:30am – 4:30pm
Fri: 7:30am – 3:00pm

We are closed on weekends.

ALLERGY CENTER HOURS

Mon: 8:30am – 11:30am and 1:00pm – 4:00pm
Tues: 1:00pm – 4:00pm
Weds: 7:30am – 11:30am and 1:00pm – 4:00pm

All allergy shots must be scheduled.

Schedule an Appointment

Click here to schedule an appointment or call (972) 402-8404. New and returning patients can request an appointment by logging into our secure patient portal.

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