Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

New Patient Forms

Patient Forms

New Patient Form– Please PRINT, complete and bring with you to your next Appointment.

Update Patient Forms– Please PRINT, complete and bring with you to your next Appointment.

Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization and Consent for Treatment (PDF) – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.

Preventive Medical Visit Patient Information (PDF) – Details financial responsibilities regarding preventive medical visits.

Financial Policy

Financial Policy

Loudoun ENT Specialists Credit Card on File Policy

Loudoun ENT Specialists requires that a valid credit card be kept on file.
This policy is designed to:

  • Help you avoid all billing related fees
  • Streamline the billing process in our office and eliminate the expenses related to handling overdue accounts
  • Focus our time and energy on your medical care

The card information is stored electronically in an encrypted form and cannot be viewed by our office staff. Your signature will authorize the card to be used only when your balance becomes past due.

How the policy works:

  1. At the time of registration or check-in, you will be asked for your credit card information to be electronically stored in encrypted form in our computer. Only the last four digits are visible to our staff.
  2. As before, we will bill your insurance carrier as a courtesy for all charges related to the visit.
  3. When we receive an explanation of benefits (EOB) from your insurance, we will send you a statement. If we have not received payment within 30 days, we will charge the credit card on file for the balance due (on the statement).
  4. If Loudoun ENT Specialists attempts to use your card and it is declined or has expired, Loudoun ENT Specialists will send you a new statement with a note attached asking for current credit card information. If no new information is provided, the account will be forwarded on to our collection agency.

Please remember that this policy does not restrict your right to appeal any charge made to your credit card. Should you feel that we have charged your card in error, you may contact our billing office. If a mistake has been made we will reverse the charges.

What You Should Know

What You Should Know


If you have a life-threatening emergency, DIAL 911 or go to the nearest emergency room. For urgent ENT problems occurring during regular business hours call our office. For after-hours ENT emergencies, DIAL 703.257.3964 and ask for the ENT Specialist on call. Dr. Vasquez is not always the ENT on call. Please reserve non-urgent calls for normal business hours. Limited same day or next day appointments are available.


Appointments are available Monday through Thursday 8:30 am – 4:30 pm and Fridays 8:30 am – 2:30 pm. We also offer same day and emergency appointments (limited availability).


Dr. Vasquez typically schedules surgeries once a week at either Reston Surgery Center or Loudoun Ambulatory Surgery Center.


It is our office policy to charge a $75 fee for any failure to show or canceling your appointment the same day.


Verification of coverage is performed prior to the time of the visit. Any patient financial responsibility will be collected at the time of the visit. If you want to know what you will be paying please call your insurance before your visit. We are a specialist practice and we perform diagnostic testing. It is in your best interest to know your insurance benefits. Patients with out-of-network benefits and self-pay patients are always welcome. If you have concerns regarding payment, please speak with the Receptionist or Office Manager.