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Patient Intake Form

Click Here To Download and Print Your Medical Forms Packet

If you need assistance in printing the above PDF or in troubleshooting, check out this guide.

What’s Inside the Medical Forms Packet:

  • HIPAA Patient Privacy
  • Patient Information
  • Self-Assessment
  • Medical Release

What to expect when you come for your appointment:

  1. To see a licensed Doctor of Audiology who will test your hearing and diagnose the type of hearing loss, if any, you have.
  2. To be treated with dignity and respect as a treatment plan for the hearing loss is discussed and agreed upon.
  3. To be given the necessary time and attention throughout the treatment process to ensure successful outcomes.

When you come for the appointment we would like you to:

  1. Please bring a family member or close friend to provide a familiar voice.
  2. Bring the enclosed completed paperwork and active insurance cards.
  3. Bring a list of all medications and supplements you are currently taking.
  4. Be prepared to hear better than you have for some time!!!!
Why wait? You don't have to live with hearing loss. Call Us Today