Please print out this form, fill it out, and mail (or fax) it to the address below.

Stanford University
Department of Otolaryngology - Head & Neck Surgery
801 Welch Road
Stanford, CA 94305
Voice: (650) 723-5281
Fax: (650) 644-3350

Confidentiality Notice: this form may contain confidential medical information. The information in this form is confidential and privileged. It is unlawful for an unauthorized person to review, copy, disclose or disseminate confidential information. If the reader of this warning is not the intended recipient or agent, you are hereby notified that you have received this form in error and that review or further disclosure of the information contained therein is strictly PROHIBITED. If you have received this form in error, please notify us immediately at the telephone number indicated above and return the original message to us by mail. Thank you.

Patient Name: ________________________________________________
Date of Birth: _______/_______/_______
Male or Female: ____________________
Address Line 1: ________________________________________________
Address Line2: _________________________________________________
City: _______________________________________
State: _______________________ Zip Code: ______________
Race: _________________ Marital Status: _________________
Language Needed: ___________________________
Social Security Number: ______-_______-________
Stanford Medical Record Number (if known): ___________________
Home Telephone: (______)__________________
Work Telephone: (______)__________________
Cellular Telephone: (______)________________
FAX: (______)__________________

Primary Insurance Provider: ___________________________
Patient Group #: ___________________________
Patient Subscriber ID: _______________________
Type of Ins. (HMO, PPO, EPO, POS, MediCare, MediCal)________
Telephone Number for Eligibility: (______)____________________
Subscriber Name: ________________________________________

Work Status (Full-Time, Part-Time, Retired, Student): _______________
Occupation: _________________________________________________
Employer Name: _____________________________________________
Address Line 1: ______________________________________________
Address Line 2: ______________________________________________
City: ______________________ State: ___________ Zip: ____________
Telephone: (_______)_______________________

Emergency Contact :
Contact Name: ___________________________
Pt. Relatationship to Contact: ______________________
Address:______________________________________
City/State: _____________________
Zip Code: ____________
Tel: _________________
Work: _______________
Alt: _________________
Alt Phone Type: _______________

Referring Doctor: __________________________________________
Address Line 1: _____________________________________________
Address Line 2: _____________________________________________
City: ______________________ State: __________ Zip: ____________
Telephone: (_______)_______________________
FAX: (________)________________

Primary Care Doctor: ________________________________________
Address Line 1: ______________________________________________
Address Line 2: ______________________________________________
City: ______________________ State: __________ Zip: _____________
Telephone: (_______)_______________________
FAX: (________)________________

Reason for Visit: ____________________________________________

___________________________________________________________

___________________________________________________________

Desired Appointment Dates and Times:
1)__________________________________________
2)__________________________________________
3)__________________________________________

Insurance Authorization Number (if applicable)__________________