BH ENT - Book Appointment

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COVID-19 Screening Questions
Have you had a fever in the past 24 hours above 100.4°F? *

Yes No
Do you have, or have recently developed, any of the following symptoms: Cough, Fever, Headache, Loss of Smell, Loss of Taste, Muscle Aches, Shortness of Breath, Sore Throat? *

Yes No
Have you been in contact with anyone in the past 14 days that has symptoms or has been diagnosed with COVID-19? *

Yes No
Have you traveled out of the state in the last 14 days? *

Yes No
Where did you travel? *
Patient Information
Have you been or are you currently a patient of BergerHenry ENT? *

Yes No
Name *

First Name Last Name
Cell Phone *

Area Code Phone Number
Other Phone

Area Code Phone Number
Email *
example@example.com
Preferred Method of Contact
Address

Street Address

Street Address Line 2
City
State
Zip / Post Code
Birthdate *

Month Day Year
Date
Insurance Provider *
Insurance ID *
Pharmacy Name (if applicable)
Pharmacy Phone

Area Code Phone Number
Family Doctor
Reason for Visit/Symptoms *
Have you had any studies done for this issue?

Yes No
What type of study did you have and where was it performed?
Would you prefer to be seen at a specific BergerHenry ENT office location?
Would you prefer to be seen by a specific BergerHenry ENT specialist?
How did you hear about us?
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