Capital Region Special Surgery medical office Albany, NY

A multi-disciplinary practice dedicated to state-of-the-art care.

Medical specialists Albany New York

Ear Institute Patient Forms

New patients are asked to complete several important questionnaire forms. This information is required to assure you will receive the best medical care.  These forms are available below (Adobe Acrobat format-PDF) to print and complete prior to coming in for your first appointment.


NYS Medicaid Statement ENT

Dizziness and Balance Medical Question
Face Sheet

History Form
HIPAA Statement
Insurance Guarantee
Office Policies
Release of Information Form
Specialist Treatment Waiver
Tinnitus History Questionnaire
Workers Compensation Form

For established patients, we also offer a secure, encrypted patient portal that provides an efficient alternative to phone calls and office visits when you have non-urgent healthcare needs: Request or Cancel Doctor Appointments; Request Medication Refills; Send a Note to Your Provider.  Call our office for information on how to activate your account.

Fields marked with an * are required

If this is an emergency or life-threatening situation, please call 911. Questions related to surgery scheduling, cancellation, rescheduling or pre-operative exams must be conducted via telephone or in-person with our surgical scheduling staff during normal business hours.

Have you had any of the following imaging studies done as they pertain to your requested appointment?