Mary Czerny, MD Office and Other Patient Information
Welcome to Baptist ENT Specialists. To help expedite your first visit, we provide our health forms online so that you can print and complete them at your convenience. If you have any questions, please don’t hesitate to contact our office staff.
Baptist ENT Specialists Forms
Authorization for Use of Voicemail
Authorizes Baptist Health to leave appointment, referral and test results information on your voicemail.
ENT Communications Policy Agreement
This form authorizes us to contact you, as well as agree or decline enrollment in the myBaptistConnect patient portal.
ENT Medical Questionnaire
ENT Notice of Privacy and Authorization to Release Information
Notice of Privacy and Authorization to Release Information
ENT Patient Information
This checklist details all the things you need to do before your visit, and what to bring. You'll also need to complete the form with information about the patient, their insurance and billing details.
ENT Policies and Acknowledgments
Policies and Acknowledgments