Date of Birth
Location Preferred*
ANY OFFICE
Schaumburg, IL Office
Rockford, IL Office
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Insurance*
Aetna Choice POS PPO
Aetna Medicare Advantage
BCBS IL - PPO
Cigna Open Access PPO
Humana PPO
Imagine Health
Medicare
Multiplan
RailRoad Medicare
Tricare
Self Pay
Other
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Symptoms (select all that apply)*
Postnasal drip
Chronic cough
Allergic thinitis
Recurring infections
Nasal obstruction
Stuffy nose
Runny nose
Loss of smell
Facial pressure
Congestion
Recurring bleeding from nose
Obstructive sleep apnea
Snoring
Choking in sleep
Enlarged tonsils
Morning headache
Morning fatigue
Mouth breathing
Gradual hearing loss
Ear fullness
Ear pressure
Vertigo
Dizziness
Imbalance
Tinnitus
TMJ/TMD
Jaw clicking
Jaw popping
Jaw lock
Ear pain
Teeth pain
Tension headache
Head pain
Neck pain
Cluster headaches
Trigeminal neuralgia
Bruxism
Teeth clenching
Teeth grinding
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Doctor*
ANY PROVIDER
Ryan Vaughn, MD
Jeffrey Ksiazek, MD
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