We are excited to announce that we have moved to a new user-friendly online payment system. This system will prompt you to create an account the first time you process your payment.
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
The free Adobe® Acrobat® Reader allows you to view, navigate, and print PDF (Portable Document Format) files. Click Here to download Adobe Acrobat Reader.