New Patient Packet Posted on January 23, 2025 by Coastal Carolina Otolaryngology Step 1 of 6 16% Coastal Carolina Otolaryngology Patient Name (First)Patient Name (Last)Preferred NameDate of Birth MM slash DD slash YYYY AgePlease enter a number from 0 to 150.Sex M F Marital Status M S D W Social Security NumberMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country CellHomeEmployerWorkEmail Local Pharmacy InformationPlease include a local pharmacy; if you do not have one, please let the front office staff know. Pharmacy NamePharmacy AddressPharmacy PhoneGuarantor/Guardian (For patients UNDER 18 years of age)NamePhoneRelationship to PatientDate of Birth MM slash DD slash YYYY Legal Guardian? (Guardianship documentation is required at time of check-in.) YES NO Emergency Contact Information NameRelationship to PatientPhoneInsurance InformationPrimarySecondaryPolicyholder Information Please make sure to fill out this portion if the patient is not the policyholder. We need this information in the event we have to schedule surgeries or procedures and to obtain billing benefits. NamePhoneRelationship to PatientDate of Birth MM slash DD slash YYYY Date MM slash DD slash YYYY Signature (Or Signature of Parent/Guardian if Under 18 Years of Age )3822 Mayfair Street, Myrtle Beach, SC 29577 | Phone: (843) 449-6449 1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | Phone: (843) 215-1068 Patient Medical History QuestionnairePatient Name (First)Patient Name (Last)Date MM slash DD slash YYYY Medical History Please list all illnesses (e.g., cancer, diabetes, high blood pressure, stroke, heart attack, etc.). Add RemoveSurgical History Please list all of the surgeries that you have had and the approximate date performed. Add RemovePlease list all illnesses that run in your immediate family. List maternal or paternal, including grandparents. Add RemoveDo you currently smoke or use tobacco products: Y N If yes, age started?How much per day?If you are a former smoker, at what age did you start/stop?Do you drink alcoholic beverages?How much in an average week?Allergy HistoryPlease list all allergies (both to medications and environmental allergens) that you have. Add RemoveCurrent MedicationsPlease list all current medications and their dosages if known, or allow us to copy your list. *Include over-the-counter medications. Add Remove3822 Mayfair Street, Myrtle Beach, SC 29577 | Phone: (843) 449-6449 1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | Phone: (843) 215-1068 Is there a possibility that you may be pregnant? Y N Have you had or do you have hepatitis? Y N Have you had or do you have HIV? Y N Review of Systems: Please answer the following questions regarding how you feel currently. Do you or have you recently had any of the following? EYESVisual changes in the past year? Y N Glaucoma? Y N Double or blurred vision? Y N Pain, redness or dryness? Y N EARSDo you currently wear hearing aids? Y N Date of purchase?Hearing problems? Y N Ringing in the ears? Y N Discharge from the ears? Y N Loss of balance/vertigo? Y N Ear pain? Y N Pressure in the ears? Y N Frequent ear infections? Y N History of loud noise exposure? Y N NOSE Nasal congestion? Y N Nasal discharge? Y N Post-nasal drip? Y N Loss of smell? Y N Frequent nosebleeds? Y N Snoring? Y N Injury to the nose? Y N Nasal or sinus surgery? Y N Frequent sinus infections? Y N THROATSore throat? Y N Frequent throat infections? Y N Painful or difficult swallowing? Y N Hoarseness? Y N HEARTHeart problem? Y N High blood pressure? Y N Angina/chest pain? Y N CHESTAsthma? Y N Bronchitis? Y N Shortness of breath? Y N Wheezing? Y N Chronic cough? Y N Cough up blood? Y N History of tuberculosis? Y N DIGESTIVEHeartburn/ulcers? Y N BLOODAnemia? Y N Easy bruising? Y N Received transfusions? Y N The above information is true and correct to the best of my knowledge.Printed Name (Signature):Date MM slash DD slash YYYY Authorization for Release of Information First NameLast NameDate of Birth MM slash DD slash YYYY CCOA is authorized to release protected health information about the above-named patient to the entities listed below.Entity(ies) to Receive InformationSpouse NameSpouse PhoneThis entity may receive health information about: Clinical information Billing information All Parent NameParent PhoneThis entity may receive health information about Clinical information Billing information All Other NameOther PhoneThis entity may receive health information aboutThis entity may receive health information about Clinical information Billing information All Information is not to be released to anyone but me If yes, check here VoicemailPlease call Home Cell Work If unable to reach me You may leave a detailed message. Please leave a message asking to return your call only I understand that I have the right to revoke this authorization at any time. I have the right to inspect or copy the protected health information to be disclosed asdescribed in this document. I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.This authorization will be in effect until revoked by the patient.Signature (print full name)Date MM slash DD slash YYYY 3822 Mayfair Street, Myrtle Beach, SC 29577 | Phone: (843) 449-6449 1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | Phone: (843) 215-1068 Acknowledgment of Receipt of Notice of Privacy Practices Patient Name (First)Patient Name (Last)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I have received a copy of the Notice of Privacy Practices for the above-named practice.Signature (print full name)Date MM slash DD slash YYYY 3822 Mayfair Street, Myrtle Beach, SC 29577 | Phone: (843) 449-6449 1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | Phone: (843) 215-1068 Financial PolicyIf you are covered by health insurance, please provide your insurance information to the front office staff, and we will be happy to bill your insurance. Accepting your insurance information does not place any financial responsibilities onto this practice, and you will be held accountable for any unpaid balances. Based on the limits of your insurance plan benefits, not all diagnostic tools and procedures performed by our practice may be considered inclusive with the office visit. You, the patient, would be financially responsible for any amount applied to your deductible, out-of-pocket expense, coinsurance amount or noninclusive amount. Copayments are collected at the time of service. Any other balances are due upon receipt of a statement from our office. No-show appointments are subject to a $35 missed appointment fee. Completing insurance forms, copying medical records, etc., requires office staff time and physician time away from patient care, so we require payment for completing forms or copying medical records. The charge is determined by the complexity of the form, letter or communication. I authorize the release of medical or other information necessary to process insurance claims, and I authorize payment of the medical benefits directly to this practice for services rendered.Patient Name (First)Patient Name (Last)Date of Birth MM slash DD slash YYYY Parent or Responsible Party (if patient is under 18 years old)Signature (pint full name)Date MM slash DD slash YYYY 3822 Mayfair Street, Myrtle Beach, SC 29577 | Phone: (843) 449-6449 1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | Phone: (843) 215-1068
