Documents

The following is our patient registration form which will share with us your contact information and allow us to care for you.

Please download and fill in the blanks. It is form-fillable in Adobe or Preview. You may print it out and bring it with you to the appointment, or you may save it and email an attachment back to us at [email protected] or [email protected]

If it is filled out in advance, your appointment should move along more quickly.

The following is the referring physician form.  Please note the person having referred you to us.  As well, please add any physician or other provider you might want to learn what went on at your appointment.  If you would like a copy of the visit notes Dr Thomas will prepare, please note that on this form.  We also ask you to make note of any other person you would allow us to talk to about your care, even a family member. Otherwise, we would only talk with you.

Please print, fill out, scan, and email back to [email protected] or [email protected], or just bring to the appointment.  We will soon make this form fillable as well.  

If it is filled out in advance, your appointment should move along more quickly.

The following is our Notice of Privacy Practices pamplet - HIPAA.

Please fill out this form to describe your most recent Botox injection experience (ABductor type).

Please fill out this form to describe your most recent Botox injection experience (Palate Myoclonus type).

This consent form is for Collagen injections.

This consent form is for Microlaryngoscopy surgeries.

Generic surgical consent form.

We are located in Portland, Oregon. Click here for the google map, or print out our 2-page driving map below. Please click the .pdf link to launch the form.