Columbus Otolaryngology Clinic
 

Patient Registration-Print

 

Complete Patient Registration Manually Using Pen or Pencil

Print Out Forms on Your Printer

Send via FAX, Postal Mail or Bring to the Office

For your convenience, select an option shown below

Option #1
Adults (Patients 19 and over) - Not due to Accident or Injury
Link to Adult Registration - No Accident or Injury

Option #2
Adults (Patients 19 and over) - Due to Accident or Injury
Link to Adult Registration - Accident or Injury

Option #3
Minor (Patients 18 and under) - Not due to Accident or Injury
Link to Minor Child (18 & under) Registration - No Accident or Injury

Option #4
Minor (Patients 18 and under) - Due to Accident or Injury
Link to Minor Child (18 & under) Registration - Accident or Injury

 

Columbus Otolaryngology Clinic

American Board of Otolaryngology Certified - Founding Member of the American Board of Medical Specialties (ABMS)

Nila M. Novotny, M.D.

Paul S. Sherrerd, M.D.

James Mathew Weekly, M.D.

 

4508 38th St., Suite #152

Columbus, NE 68601-1668

402-562-4720 FAX: 402-562-4721

Emergency call 911

 

Select One of Our Secure Options Below

Online Patient Registration

Link to HIPAA Page of Columbus Otolaryngology ClinicLink to State of Nebraska HIPAA Web Site

Link to Home Page of Columbus Otolaryngology Clinic Link to Locations Page of Columbus Otolaryngology ClinicLink to Insurance Page of Columbus Otolaryngology Clinic
Link to Online Forms Page of Columbus Otolaryngology Clinic Link to Education Page of Columbus Otolaryngology Clinic Link to Procedures Page of Columbus Otolaryngology Clinic

 

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