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Ear, Nose & Throat Specialties – New Patient forms

ENT Authorized User
Authorized User/
Authorized Representative
ENT_Cancellation_Policy
Cancellation/No Show
Procedure Consent
ENT_Minor_Treatment
Permission to
Treat a Minor

Ear, Nose & Throat Specialties forms

ENT_Privacy_Information
Notice of Privacy Practices
ENT_Dizziness_Questionnaire
Dizziness Questionnaire
(only if instructed)
ENT_Workers_Compensation
Workers’ Compensation
(only if instructed)
ENT_Liability_Information
Liability Information
(only if instructed)
abrform
Auditory Brainstem Response (ABR) Testing

Surgical Center forms

PSC_Sinus_Surgery_Post-op
Endoscopic Sinus
Surgery Instructions
PSC_Tonsillectomy_Post-op
Tonsillectomy and
Adenoidectomy
Instructions
PSC_Advance_Directive
Advance Medical
Directive
PSC_Notice_of_Privacy_Practices
Notice of Privacy Practices
PSC_Patient_Rights
Patient Rights and Responsibilities

Ear, Nose & Throat Specialties, PC
5055 A Street, Suite 300  •  Lincoln, Nebraska 68510
402-488-5600  •  Fax 402-488-7649