This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submission.
 

Personal Information










Gender
Marital Status




About Your Hearing

Do you have any of the following symptoms?
 
Difficulty in hearing:
Noise in hearing:
Pain in hearing:
Drainage from your ears:
Fullness or stuffiness in your ears:
Dizziness or balance problems?
Had a previous hearing exam?
Worn hearing aids before?
  
 

Financial Information

Primary Insurance




Secondary Insurance