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Patient Information

First Name:

Middle Name:

Last Name:

Has your child had persistent fluid in the middle of either ear for more than three months? Yes No

Which ear has the infections?

If other, please specify.

Has your child ever had ear tubes placed before? Yes No

Approximate date of last ear infection:

Are there concerns about hearing loss or speech delay? Yes No

Patient 18 months or younger: Did they pass their new born hearing screening? Yes No

Patients between 18 months and 5 years old: Have they had a hearing screening done? Yes No

Patients older then 5: Did they pass their hearing screening completed by either their primary physician or their school? Yes No

Excluding ear concerns, is your child healthy? Yes No

If you answered no please list all past medical history.

Has your child ever had surgery before? Yes No

If you answered yes please list all surgical procedures.

Disclaimer

Federal mandate prevents the likelihood for pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. 42 U.S.C. § 1320a-7b. This would include Medicare, Medicaid, and Tricare. I have fully read the above disclaimer and confirm that I am not covered by Medicare, Medicaid, or Tricare.

Is the patient currently enrolled in any Medicare, Medicaid, or Tricare programs? Yes No

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Congratulations you have met the initial qualifications. Please fill out the form below to continue to schedule

TubesToday follows all the HIPAA federal security guidelines. All information entered here will remain private and secure.

Patient:

Patient's Relationship to Insurance Policy Holder:

Patient's Date of Birth:

Patient's Gender: Male Female

Guardian's Name

First Name:

Last Name:

Guardian's Relationship to Insurance Policy Holder:

Primary Contact Number:

Primary Phone Type:

Secondary source of contact:

Phone Type:

Street Address:

City:

State:

Zipcode:

Primary Care Provider (Pediatrician)

First Name:

Middle Name:

Last Name:

{if you currently don't have a primary physician, list the last physician patient saw}

Primary Care Provider Contact Phone

Insurance Name:

Member ID:

Subscriber on Insurance Policy

As printed on insurance card.

Same as guardian

First Name:

Middle Name:

Last Name:

Subscriber's Date of Birth:

Subscriber's Gender:

Who were you referred by? Self-referred PCP referred Other

How did you hear about TubesToday?

This program is for individuals 6 months and older and with no major medical problems. Guardian will be contacted by the surgeon’s office to further discuss TubesToday process. If your child does not the meet criteria or if you are not interested in proceeding, you will be offered a conventional appointment for consultation.

Spam Guard

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