Patient Intake Form
ENT Clinic
Capture Data and Complaints
By proceeding, I confirm that I have read and agree to the
terms and conditions
.
Full Name
Date of Birth
Health Card Number
Date of Last Visit (if known)
Referred by (e.g. Family Doctor)
Select main category of your problem
Please select a category...
Ear Problems
Nose Problems
Throat Problems
Voice / Swallowing Problems
Other / Not sure
Select a more specific problem
Description
Medications
Allergies
Submit Data