Please bring these 3 completed forms to your 1st appointment with us.
Patient Registration
Medical History
Financial Policy
Other forms that may be helpful during your visit:
Dizziness Questionnaire - If you are coming to see us for dizziness, imbalance, lightheadedness concerns
Head Nose - If you are coming to see us for hearing issues and Tinnitus
For convenience you are welcome to fax your completed forms to us at 804-282-1043. We just ask that you please fax them at least 48 hours prior to your visit.
Ear Tube Placement
Tonsillectomy/Adenoidectomy Post Op & Diet Instructions
ALL Ear Surgeries (excluding Ear Tubes)
Neurotologic Patients
Labyrinthectomy and Endolymphatic Sac Surgeries
Cochlear Implants
Nasal Surgery
VIVAER Procedure
There is a flat service fee of $15 for us to compile and electronically send your records to your desired location. If you would like to have them printed it would cost the standard $15 service fee and an additional $1 per piece of paper plus the cost of postage. Please complete our Request Medical Records form and send to us. We unfortunately are not able to accept verbal request. Only written request will be honored. For convenience you are welcome to fax your completed forms to us at 804-282-1043 or email the completed form to medicalrecords@shaiamd.com (not HIPAA complaint). Our goal is to have your request completed within 48 hours, however, due to the heavy schedules our employee and physician work, we can only guarantee a 5-business day turnaround time.