REQUEST AN APPOINTMENT
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
Cell Phone Provider
*
AT&T
Sprint
T-Mobile
Verizon
Boost Mobile
Consumer Cellular
Cricket
Good 2 Go
Metro
Mint Mobile
Red Pocket Mobile
Simple Mobile
Spectrum Mobile
Straight Talk Wireless
Tello
Total Wireless
Twigby
Ultra Mobile
US Mobile
V*s*ble
Other
Other Phone
-
Area Code
Phone Number
Email
*
example@example.com
Preferred Method of Contact
Phone
Email
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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?
East Norriton, PA - ENT CENTER
Willow Grove PA
Chestnut Hill, PA
Lansdale, PA
Oaks, PA
Roxborough, PA
Not partial to any BergerHenry ENT location
Would you prefer to be seen by a specific BergerHenry ENT specialist?
Todd C. Morehouse, D.O.
Marta T. Becker, M.D.
Donald M. Sesso, D.O.
Lana B. Patitucci, D.O.
Lindsay A. Goodstein, M.D.
Meghan L. Brooking, D.O.
Not partial to any BergerHenry ENT specialist
How Did You Hear About Us?
Google Ads
Yahoo
Bing
Referring Physician
Friend
Family Member
Other
Request Appointment
Should be Empty: