Patient Forms

If you are a New Patient, please call our office at 402.488.5600 to request access to our patient portal. This will allow you to save time by filling out and completing new patient forms online prior to your appointment.

Click on any of the form icons below to download an Adobe Reader® file of that form. Print, complete and return the forms at your next appointment.

If you don’t have Adobe Reader on your computer click here for a free download.

Ear, Nose & Throat Specialties forms

Notice of Privacy Practices

Dizziness Questionnaire
(only if instructed)

Workers’ Compensation
(only if instructed)

Liability Information
(only if instructed)

Auditory Brainstem Response (ABR) Testing

Click on the appropriate permissions or records request form icons below, fill it out online and hit submit. This will securely send your request to the appropriate department for processing.

Permission to
Treat a Minor

Release of records from
another office

Release of records to
another office

Release of records to
the patient

Surgical Center forms

Endoscopic Sinus
Surgery Instructions

Tonsillectomy and
Adenoidectomy
Instructions

Advance Medical
Directive

Notice of Privacy Practices

Patient Rights and Responsibilities