Patient Forms and Requests
Below you’ll find different options related to our patient forms and your requests. First you’ll find our secure Online options. The Online options are followed by download options and additional “other” forms for download/print – Completing your forms and/or requests online is more efficient, but you may choose your preference.
NOTICE TO NEW PATIENTS: If you have an appointment and will be filling out your forms Online, please complete both the Patient Registration form AND the Adult (or Pediatric) Health History form.
Online Requests and Patient Forms
Please use our universal online request form to request an appointment, ask questions, medication refills, lab and test results, and medical records release.
New patients, please complete both registration and applicable health history forms. Current patients, please complete the health update form based on the instructions below. If it has been more than three years since you have been seen at our practice, please complete the “New Patient” forms, rather than the update forms.
CURRENT PATIENTS – The form below is for any patient who was seen at SFOMG over 1 year ago but less than 2 years ago.
Download/Print Patient Forms
We also provide the option of download and print of our forms.
The physicians and staff at San Francisco Otolaryngology want to be sure we are taking good care of our patients.
We would greatly appreciate if you took a few minutes to fill out our one question survey.
We look forward to meeting you on your initial visit to our offices. Our completely electronic medical record allows us to provide you with the highest quality care and optimal communication with your other health care providers. In addition, we know that every patient is different and has specific needs, and we will strive to provide you with personal, individualized attention.
What To expect
ENT doctors, or Otolaryngologists, are trained in the medical and surgical treatment of patients with diseases and disorders of the ears, nose, throat (ENT), head, and neck. ENT is a subspecialty and requires specialized equipment to thoroughly examine and properly diagnose a patient’s complaint.
We understand that patients may be unfamiliar with these ENT techniques and equipment. Listed below is an idea of what to expect in an ENT consultation. However, not all of these methods will be necessary in every consultation and the techniques will vary given the individual needs of the patient and the nature of the complaint.
Please prepare for your visit by bringing:
- Health Insurance Card/Information
- A list of all medications you are taking
- A list of your questions /concerns
- A copy of your XRAYS / CT scans (not just the reports – please get the actual films as well on CD if possible)
- Copies of records and/or imaging from doctors related to your sinuses/nose/allergies/lungs on CD if possible.
Self – Assessment Questionnaires, as applicable
If you think you are affected by any of the following conditions, please print the self-assessment test and bring completed form with you to your appointment.
Secure Patient Portal – We invite you to log in to your online account or create a new online account. Take advantage of the online services offered by our practice with the assurance that all of your information is encrypted and stored securely. We utilize UCSF’s MyChart portal, and you may access the following from your account:
- Access all online services offered by your physician
- Update demographics and insurance
- Update e-mail address
- Update username and password
- View history of previous visit
Billing & Insurance Payments
We accept most PPO’s, Medicare and the following Medical Group HMO’s:Brown and Toland Medical Group, Hill Physicians Medical Group, and Meritage Medical Group. HMO’s. You will be responsible for ALL co-pays, deductibles and non-covered services. We accept Visa, Mastercard, and personal checks.
For questions regarding your billing statement and/or benefits, please contact the billing office:
Phone: (833) 353-6885
Patient Electronic Health Record Notification
As part of our commitment to patients in providing the highest quality healthcare services, the physicians and staff of this office utilize an electronic health record (EHR) system. The EHR system allows our physicians and staff to consolidate, store, retrieve and share medical information about a patient’s medical history. The EHR is endorsed as a way to increase accuracy, improve efficiency and reduce medical errors. Medical records are created when you receive treatment from a health professional, as you do from our office. Records may include your medical history, details about your lifestyle (such as smoking or involvement in high-risk sports), and family medical history. In addition, your medical records contain chart notes, consultation notes, laboratory test results, medications prescribed, and reports that indicate the results of operations and other medical procedures. Information will be entered directly or scanned into a web based medical record system in the computer. This chart is connected to a network of physicians and offices associated with the UCSF Medical Center. Your medical records are shared in the epic network and may be accessed by other physicians within the system. In turn, this office has access to records generated by other network physicians who see you and these records are shared only where there is a treatment relationship. The EHR has levels of security to protect against inappropriate access or disclosures. We believe patient care will be enhanced by immediate access to information we might not know otherwise exists.
If you have any questions or concerns, please discuss them with your physician or call our office for further assistance.