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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
First Name
Middle Initial
Last Name
Address
Address Line 2
City
State
Choose your state
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone
Secondary Phone
Email
Gender
Male
Female
Birthday
Marital Status
Single
Married
Name of Spouse
Occupation Status
Current
Retired
Occupation
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship:
...choose contact
Mother
Father
Wife
Husband
Daughter
Son
Sister
Brother
Other Relative
Friend
Referred By:
...choose referrer
Spouse
Friend
Physician
Print Advertising
Online Advertising
Billboard
Other
Referrers Name/Details
Medical History
Primary Care Physician
Primary Care Physician Phone
Please send a copy of my audiological findings to my physician
Yes
No
Have you ever seen a doctor specializing in diseases of the ear (ENT)?
Yes
No
When did you see the ENT?
Provide the details of the ENT visit
Have you ever had any type of ear surgery?
Yes
No
When did you have ear surgery?
Provide the details of the surgery.
Are you diabetic?
Yes
No
Diabetes Type?
About Your Ears
Do you have any of the following symptoms?
Difficulty hearing:
No
Both
Left
Right
Hearing noise (ex. ringing, clicking, static):
No
Both
Left
Right
Pain in ear:
No
Both
Left
Right
Drainage from your ears:
No
Both
Left
Right
Fullness or stuffiness in your ears:
No
Both
Left
Right
Dizziness or balance problems?
Yes
No
Sudden or Rapid Hearing Loss (in the last 90 days)
Yes
No
About Your Hearing
How long have you had a hearing problem?
Have you ever had your hearing tested?
Yes
No
When was your hearing tested?
Tested by?
Does anyone else in your family have a hearing problem?
Yes
No
Relationship to you?
Have you worn hearing aids before?
Yes
No
Hearing Aid Brand?
Previous Hearing Aid Details (results/comments)
Do you experience difficulty with:
Understanding all the words in conversation clearly?
Yes
No
Hearing in situations where background noise is present?
Yes
No
Hearing on the Phone?
Yes
No
Please describe situations when your hearing problem gives you the most trouble.
Insurance Information
Primary Insurance Name
Primary Insurance ID #
Primary Insurance Group #
Insuree
Secondary Insurance Name
Secondary Insurance ID #
Secondary Insurance Group
Insuree
Please upload a copy of your insurance card(s).
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