Patient Forms - Ashland ENT

Patient Forms

Please download the following forms, complete the forms in detail, print, and sign. You can mail, fax (419) 289-9563 or bring the forms to your scheduled appointment. Mailing or faxing the completed and signed forms will expedite the check-in process upon arriving at our office.
Thank you for your help.


Ashland ENT New Patients please complete the following forms:
  Registration Form
  Financial Policy Form (PDF)
  Patient Health History Form (PDF)
  HIPAA Notice of Privacy Practices
  HIPAA Notice of Privacy Practices - Acknowledgement Form
  Balloon Sinuplasty SNOT.20 Form

Allergy New Patients please complete the following forms:
  Registration Form
  Financial Policy Form (PDF)
  Patient Health History Form (PDF)
  HIPAA Notice of Privacy Practices
  HIPAA Notice of Privacy Practices - Acknowledgement Form
 

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Ashland ENT
2212 Mifflin Avenue Suite 130
Ashland, Ohio 44805
Phone: (419) 289-8919
Fax: (419) 289-9563
Hearing Center: (419) 289-1937 

Copyright © 2024 Ashland ENT. All rights reserved.

 Our Hours

Monday, Thursday: 8:30am - 5:00pm
Tuesday: Surgical day at Samaritan Regional Health System
Wednesday: 8:30am - 3:00pm
Friday: 7:30am - 12 noon
 
New Patients Welcomed! We participate with most insurances. Please check with your insurance plan to confirm we are a participating provider.
 
ALLERGY DEPARTMENT HOURS
Monday 7:30 - 11:30am, 1:00 - 4:30pm
Tuesday 8:30 - 11:30 am, 1:00 - 4:30pm
Wednesday: 7:30 - 11:30 am, 1:00 - 2:30 pm
Thursday 7:00 - 11:30am, 1:00 - 4:30pm
Friday 7:00 - 11:30am