We would like to take this opportunity to welcome you to our practice. Please complete the intake forms prior to your appointment date. Please try to be as thorough as possible so that we may make your visit both pleasant and efficient.
We would ask that you come to the office at least 15 minutes prior to your scheduled appointment time, so that we may process your paperwork and clarify any questions you may have. Please note that beginning October 1, 2010, a cancellation fee of $25 will be assessed for missed appointments. To avoid this fee, please provide 24 hours notice if you will miss your appointment.
Please bring to your appointment:
A. Completed patient intake forms.
- Patient Information Form
- Medical History Questionnaire Form
- Cosmetics Interest Form (optional)
- Notice of Privacy Practices/ Patient Bill of Rights
- COVID-19 Risk – Informed Consent
- COVID-19 Patient Questionnaire
- Consent for Telemedicine Consultation (optional)
B. Your referral/ authorization (for HMOs). A hand carried copy is most reliable.
C. Your insurance card.
D. Any required co-pay.
E. Proper identification (i.e. Driver?s license).
F. A list of your medications, if not already entered on the forms.
G. All pertinent medical records (X-rays, CT scans, MRIs, pathology reports, etc.).
Please understand that you will not be seen without your referral/authorization and your insurance card. It is your responsibility, as an active participant in your health care, to obtain the proper referral/authorization form. If you are not sure whether your visit will require a referral/authorization, please contact your primary care physician or call our office at (909) 981-5859. The office is quite busy and time constraints will not allow for the office staff to make phone calls to obtain your referral/authorization form on the day of service.
We look forward to meeting you and working with you to resolve medical problems relating to the ears, nose and throat. Please do not hesitate to contact the office if you should have any questions about this letter or the patient intake forms.
Natee Poopat, MD
Clara Olcott, MD
Before your appointment with us, quickly and conveniently access patient forms from our practice.
To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com. Please bring your completed forms with you to our office at the time of your visit.