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Patient Information

Welcome as new patient to Crystal Community ENT. Dr. Grillo and his staff always strive to make your visit to our office a pleasant and efficient experience. Please help us by filling out the forms below prior to your first visit. Please allot as much thought to your answers as possible by filling in the basic information needed at your home instead of in the office waiting room. Please take a moment now to click on the links below, print them out, fill in the information as required and bring the forms with you on your visit.

Please click on the links below and review this information. If you wish, you may print any of these documents out for your personal records.

New Patient Forms:

Patient Demographics

Patient History 1

Patient History 2

Patient Medication List (copies of list will not be accepted)

Patient Financial Policy

Our Office Policies

Receipt of Notice of Privacy Practices 

Established Patient Updates:

Patient History Update

Patient Documents:

Your Rights to Privacy 

Our Insurance Policy's (Insurance Information)

Patient's Rights & Responsibilities 

Arbitration Explanation

Medical Records Release

Please only print and fill out one questionnaire per visit. Even though you may feel you have all of the issues listed below. Please understand that we have not allotted enough time in our schedule to go over all of these questionnaires. If Dr. Grillo during his exam feels one of these additional forms are needed he will go over it with you at the time of your visit.

Patient Questionnaire's:

Sleep Disorder
Dizziness Questionnaire
Allergy History Questionnaire
Headaches Questionnaire
Hearing Questionnaire
Ear Questionnaire
Cough Questionnaire
Voice Questionnaire
Sinus Symptoms Questionnaire
Sinus Questionnaire
Throat Questionnaire

We want our patients to be able to comfortably afford our care. We will gladly discuss our financial policies with you before beginning your treatment. We accept credit cards for payment of services. If you carry insurance, a member of our staff will be glad to explain your benefits.

We accept VISA, MasterCard, AMEX, and Discover for credit payments.

Credit Cards

Dr. Grillo

Crystal Community ENT
790 S.E. 5th Terrace,
Crystal River, FL 34429
(352) 795-0011

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