Patient Forms

You can now download new patient forms from our website before you come in for your office visit and save time!

Please remember to bring your insurance card with you at the time of visit. Charlotte Eye Ear Nose & Throat Associates participates with most major insurance plans. To verify participation in your plan, please contact us at (704) 295-3000 or or call your insurance provider.

New Patients to our practice should complete the following new patient forms:

Eye Patients:

• Demographics Form & Medical History Questionnaire Form
• Uveitis Questionnaire : For new uveitis evaluation patients

ENT Patients:

• Demographics Form & Adult Medical History Questionnaire Form
• Sleep Questionnaire

Voice & Swallowing Patients:

• Case History Form
• Scheduled Appointment
• Attendance Policy
• Assignment of Insurance Benefits

Radiology patients

• MRI Screening Forms
• MRI Screening Forms (Spanish)

Patients With Caregivers:

• Permission to Communicate with Caregivers Form

To review our policies, please download the following forms:

• Privacy Policy
• Financial Policy
• Release of Information Form - Please allow 7-10 business days to receive a copy of your medical records. The fax number is 704.295.7794.
• Permission to Treat Form

For a list of our services that are not covered by insurance, please download:

• Non-Covered Services Form

(Adobe Acrobat is required to view these forms. If you would like to download a free copy of Adobe Acrobat Reader, please go to http://get.adobe.com/reader/)