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PreAuthorization for Providers

Patient Name

D.O.B.

Date of Exam

Are you seeing an ears, nose and throat doctor (ENT) for you sinus problems?

Yes No

Please give the name of the ears, nose and throat specialist (ENT):

Headaches

Yes No

Excess mucous production

Yes No

Visual problems

Yes No

Facial Pain

Yes No

Other Symptoms (please explain)

How long have you been having these symptoms?

Have you been on antibiotics?

Yes No

If yes, how long?

Have you had surgery?

Yes No

If yes, please explain:

Have you had cancer of the face or sinuses?

Yes No

If yes, please explain:

Have you ever had a fracture of the facial / nasal bones?

Yes No

If yes, please explain: