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

Preferred Title







Gender


















How would you like to be contacted?


















Who can we thank for referring you to our office? We like to know how our patients find our practice. Please check the MOST influential source of information about this practice.


Release of Medical Information

I herby authorize Carson Hearing Care, PLLC, to release any and all medical information in the course of my (or my child’s) treatment to:


I have been given the opportunity to read or obtain a copy of the Notice of Privacy Practices and HIPAA release/authorization.



Case History

What is your main concern?

With which ear do you hear best?

When do you have difficulty hearing?



Have you been exposed to loud noise, either recently or in the past?

Have you seen an Ear, Nose, & Throat Physician (ENT)?




Have you ever had surgery that may have affected your hearing?

Have you ever had an ear infection?





Please check any of the following that you currently have or have had in the past:











Have you had a fall or near fall in the past year?

If you have worn a hearing aid in the past, which ear was aided?