Secure Online Patient Check-In For your convenience, you may fill in this online form to detail the reason for your upcoming visit to Mann ENT and to update your health information if you are a returning patient. A RESPONSE IS ONLY REQUIRED WHERE YOU SEE A RED *ASTERISK* Patient's Name* First Last Your Name (if different) First Last Patient's Date of Birth* MM DD YYYY Phone NumberEmail Which Provider Are You Seeing at Your Appointment? Dr. Charles Mann Dr. Sam Davis Dr. Jared Spector Audiology Allergy Radiology I am not sure Check More Than One Where Appropriate.Please Confirm the Site for Your Appointment Cary Location (601 Keisler Drive, Cary, NC) Clayton Location (555 Medical Park Place, Clayton, NC) Telemedicine Appointment Please Indicate the Date of Your Appointment Date Format: MM slash DD slash YYYY This will be helpful if you are filling out this form in the days prior to your actual appointment.Referring ProviderPlease include the name of the doctor or practice that referred you to our office. If you found Mann ENT from another source, such as a friend or the internet, please let us know.Main Reason for My Visit*Please describe in a few words the reason for your visit today, and how long problem has been present. "Loss of hearing in my right ear for two days" for example. You may include more than one symptom if this is appropriate.Further Information About Your Symptoms*For each symptom noted above, please indicate the date of onset of this symptom, how long it tends to last, how often it happens, how severe it is on a scale from 1-10 (10 being the worst), any factor that makes it better or worse, and any strongly associated factors.Your MedicationsPlease list your medications here if you are a new patient, or any new medications since your last visit if you are a returning patient. You may also include any issues with medications previously prescribed by Mann ENT.Do You Have Any Allergies To Medications?If you are a returning patient, please list any new allergies that have developed since your last visit.Past Surgical ProceduresPlease indicate any surgical procedures you have undergone since your last visit with us.Past Medical ConditionsPlease tell us of any medical condition that has been diagnosed since your last visit.Any Further Information?If you would like to include anything else we should know, simply type it here.CAPTCHA
