Patient Forms
If you have made an appointment with us, then you will need to fill out informational forms prior to coming in to see the physicians.  This will save time for you at the office and is helpful for the office. Note: Only some of the forms need to be filled out.  

*If you are new to the practice or have not been seen in 12 months, you need to fill out the Registration form and the Review of Systems. The Current Medicines form is filled out for all visits.

**The other questionnaires you fill out are related to the following medical problems:  Dizziness, Thyroid problems, Children's ear infections, or Sleep Apnea. Please fill out the form related to your medical problem.

***If you have a medical problem unrelated to the above problems, please fill out the General Ear, Nose, and Throat questionnaire.

Download & 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     - AND - Fax the forms to Irving-Coppell ENT at (972) 402-9301

          IMPORTANT NOTE: A copy of the privacy policy is available for review at  www.hipaadvisory.com or at appt.


List of Patient Forms
Registration - Adult (18 yrs and older)
Please complete all blanks that are applicable. 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.

Registration - Child (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. 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.

Review of Systems  (ROS, PMH, FH, SH DATA)
Please fill in all blanks as specifically as possible to assist the doctor in your diagnosis and treatment. Mark all  applicable boxes. 
click to download form  Required for new patients or if not seen in office in 12 months.

Dizziness History
Please fill in all blanks as specifically as possible to assist the doctor in your diagnosis and treatment. Mark all boxes with an answer.  

click to download form  Only required if your main problem is dizziness

Thyroid History
Please fill in all blanks as specifically as possible to assist the doctor in your diagnosis and treatment. 

click to download form  Only required if your main complaint is a thyroid problem

Child Ear Infection History
To be filled out by the parent or legal guardian of the child. Please fill in all blanks as specifically as possible to assist the doctor in your diagnosis and treatment. 

click to download form  Only required for children with ear infections as the main problem.

Snoring,Sleep Apnea/Daytime Sleepiness and other Sleep Disorders
To be filled out by the parent or legal guardian of the child. Please fill in all blanks as specifically as possible to assist the doctor in your diagnosis and treatment. 

click to download form  This form is only needed it snoring or sleep apnea is your main problem.

General Ear, Nose, and Throat History
To be filled out if the medical problem for which you are seeing the doctor is not related to the other problems mentioned above.  Some of the questions on the form might not seem applicable to you.  Please fill the form out completely as possible and the doctors and nurses will help you with the specifics of your medical complaint.

click to download form  Only required if the other more specific questionnaires are not applicable.

Medication List
Please list the names of medications you are currently taking with dosages and how many time a day you take them. Please list over the counter medications and vitamins also.

click to download form  Required to be updated for all patients and all visits.

NOTE: Forms are in Adobe Acrobat (.PDF) format and users must have Adobe Acrobat Reader installed on their computer to view and download. Adobe Acrobat Reader can be downloaded from here. (free download from Adobe)