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Patient Information

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Phone

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Complete this section ONLY IF someone other than the patient is financially responsible

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***Please provide your insurance card(s) and driver’s license or picture ID***

Financial Agreement 
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  • Our office requires 24-hour notice for cancellation of ANY appointment. If appropriate notice is not given or you No Show you will be charged a $50 fee. 
  • Our Office will file insurance for all reimbursable services, to both primary and secondary insurance carriers. Please remember that you are responsible for all deductible, co-pay, and non-covered service amounts. 
  • I authorize use of this form on all my insurance submissions and request payment of authorized Medicare benefits and/or private insurance benefits be made to Eric L. Hensen, D.O., P.A. for services rendered to me. I authorize release of information to all my insurance companies. 
  • I understand that I am responsible for my bills. 

If we are filing insurance for your visit, we must have complete information and any required referral at the time of the visit. If you cannot provide the information, we will be unable to file your insurance, and payment in full will be required. Payment of your charges cannot be determined until the claim is submitted to your insurance company. Payment will be based on your individual health plan and the amount applied to your plan deductible and/or coinsurance will be your responsibility. Procedures which are excluded from coverage, based on your plan’s determination of medical necessity, will also be your responsibility. Your office visit co-pay is due at time of the visit and, in many cases, covers only the office visit charge. Any procedures preformed will be considered surgery by your insurance company and deductibles and coinsurance may apply. For all other patients, payment is required at the time of service. We will provide you with the necessary documentation to file for reimbursement upon your request. 

I have read the above information and understand that I am responsible for payment for the services I receive. 

Medical Information Release Form 

Due to 2003 HIPPA laws, the release of patient’s medical information has been restricted. On the form below, please list any family member, friend or others we may release information to if they were to call our office and ask questions about an appointment date, surgery date, or any other treatment questions.

Information Access Preferences 
Clinical Information / Financial

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If you checked the Restricted line above, please specify which clinical information you DO NOT wish to share with the person(s) listed above. 

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May we leave a message on an answering machine or voicemail?
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  • I understand that I can grant and/or restrict access to my private health information with Eric L. Hensen, D.O, P.A.
  • Health information is used and disclosed to carry out treatment, payment or operations.
  • I understand that Eric L. Hensen, D.O, P.A. reserves the right to deny this request dependent upon the circumstances
NEW PATIENT INTAKE AND HISTORY FORM

(PRINT PLEASE)

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REASON FOR COMING TO THE DOCTOR TODAY:
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PROBLEM LIST/PAST MEDICAL HISTORY:

Have you been diagnosed with any of the following (currently or in the past)?

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ALLERGY HISTORY:
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MEDICATION HISTORY:

List any medications, vitamins, minerals and herbals that you are currently taking:

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FAMILY HISTORY: 

Has any member of your family been diagnosed with any of the following conditions (including deceased family members)? Place an X under the family member with the condition and indicate if the family member passed away due to that condition.

Asthma

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Cancer

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COPD

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Diabetes

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Heart Disease

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High Blood Pressure

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Migraines

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Obesity

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Seizures

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Sleep Apnea

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Thyroid Problems

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PAST SURGICAL HISTORY: 

Place an X next to any surgery you’ve previously had, along with the year it was done.

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SOCIAL HISTORY:
Would you Accept a Blood Transfusion if needed?
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Please describe your current/past tobacco use, along with how much:

Never a Smoker
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Do you drink alcoholic beverages?
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Have you ever used illicit drugs?
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Describe your current sleep:

Do you drink caffeinated beverages?
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REVIEW OF SYSTEMS:

Please place a check mark in the box next to any of the following symptoms or problems if you have experienced them recently or have concerns about them. If you don’t understand something place a question mark “?” by it. Your doctor will discuss any positive responses with you.

General:       Normal

Skin:       Normal

Cardiovascular:       Normal

Gastrointestinal:       Normal

HEENT:       Normal

Musculoskeletal:       Normal

Neurological:       Normal

Neck:       Normal

Respiratory:       Normal

Psychiatric:       Normal

Endocrine:       Normal

Hematology:       Normal

Lone Star ENT, Allergy and Aesthetic Patients

This notice is to ensure you, our patient, that proper precautions are taken by our staff to protect you from any illness that is easily transferrable from person to person while in our office. Examples of common illnesses, especially during the fall and winter months are seasonal flu, common cold viruses, and Noroviruses (stomach bug). As you well know, COVID-19 has been included as well.

In order to keep our patients safe, these precautions are taken by our office staff:

-Treatment rooms are cleaned and disinfected with hospital grade cleaner between each patient.

-Disinfecting of equipment used to examine patients is done by using alcohol-based cleaner or by sterilization.

-Proper hand hygiene is done before patients are seen AND after patient care.

If, for any reason, you feel uncomfortable with precautions taken by our office, please reschedule your appointment for a later date.

If you agree to being treated in our office at this time, please sign your name at the bottom of this form with today’s date. Thank you for letting us participate in your care.

Lone Star ENT, Allergy and Aesthetics Care Team

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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