Patient Registration & Clinical Forms
The team at Memorial Village Sinus and Hearing looks forward to welcoming you. To ensure your appointment is as efficient as possible, please complete the necessary documentation prior to your arrival.
1. New Patient Registration (Required)
If you are a new patient, or if it has been more than 3 years since your last visit, please complete our secure digital registration. This form is sent to us electronically—no printing is required.
2. Health & Symptom Questionnaires
Depending on the reason for your visit, Dr. McCutcheon or Dr. Lippeatt may require specific symptom evaluations. Please print these forms, complete them, and bring them to your appointment.
- Nasal Obstruction Symptom Evaluation (NOSE)
- Total Nasal Symptom Score (TNSS)
- Sino-nasal Outcome Test (SNOT-22)
- Eustachian Tube Dysfunction Questionnaire (ETDQ-7)
3. Privacy Practices
We are committed to protecting your health information. Please review our notice regarding how your medical data is handled.
What to Bring to Your Appointment
In addition to your completed clinical questionnaires, please ensure you have the following items ready for your visit:
- Photo ID: A valid driver’s license or government-issued identification.
- Insurance Card: Your current primary (and secondary, if applicable) insurance cards.
- Medication List: A complete list of current medications, including dosages and supplements.
- Relevant Medical Records: Any recent CT scans (on a disc), X-rays, or previous allergy testing results from other providers.
Note: If you are visiting us for a hearing evaluation, please ensure your ears are clear of significant wax buildup prior to your appointment to allow for accurate testing.
