Guadalupe Ear, Nose, and Throat, P.A.

Jennifer G. Hennessee, M.D. Lisa M. Wright, PA-C

1Patient Demographics > 2Authorizations/Consents > 3Patient Health History
Patient Profile
Name Name First Middle Last
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female
Social Security Number
Marital Status

Marital Status Single Married Divorced Widowed
Email
Preferred Language
Race
Ethnic Group
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Mobile Phone Mobile Phone - ### - ### ####
Alternate Phone (if any) Alternate Phone (if any) - ### - ### ####
Guadalupe ENT, PA provides the option for you to receive your account billing statements / invoices by email. I understand that by agreeing to receive billing statements / invoices, by email, it is my responsibility to maintain a current email address on file. I do understand that by agreeing to receive electronic mail, I will not receive any statements or invoices by US mail.
Do you consent to receiving billing statements from Guadalupe ENT, PA by email?

Do you consent to receiving billing statements from Guadalupe ENT, PA by email? Yes No
Preferred Email Address to send billing statements / invoices:
Insurance Information
Primary Insurance
Primary Ins. Policy Number
Primary Ins. Group Number
Policy Holder Policy Holder First Last
Policy Holder Date of Birth Policy Holder Date of Birth / MM / DD YYYY
Relationship to Patient
Policy Holder Social Security Number
Policy Holder Address Policy Holder Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Policy Holder Employer
Secondary Insurance
Secondary Ins. Policy Number
Secondary Ins. Group Number
Policy Holder Policy Holder First Last
Policy Holder Date of Birth Policy Holder Date of Birth / MM / DD YYYY
Relationship to Patient
Policy Holder Social Security Number
Policy Holder Address Policy Holder Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Policy Holder Employer
Emergency Contact
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Address Emergency Contact Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Emergency Contact Alt. Phone Emergency Contact Alt. Phone - ### - ### ####
Relationship to Patient
Emergency Contact Name #2 Emergency Contact Name #2 First Last
Emergency Contact #2 Phone Emergency Contact #2 Phone - ### - ### ####
Relationship to Patient

Guadalupe Ear, Nose, and Throat, P.A.

Guadalupe Ear, Nose, and Throat, P.A.

Patient Profile

Insurance Information

Emergency Contact