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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
Email
Gender
Male
Female
Birthday
Marital Status
Single
Married
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
Family
Friend
Physician
Marketing
Other
Not Applicable
Reffering Physician
About Your Hearing
Do you have any of the following symptoms?
Difficulty in 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
Had a previous hearing exam?
Yes
No
Previous exam by?
Worn hearing aids before?
Yes
No
Previous Hearing Aid Details
Financial Information
Payment Type (Cash or Insurance)
Primary Insurance
Primary Insurance Name
Primary Insurance ID #
Primary Insurance Group #"
Insuree"
Secondary Insurance
Secondary Insurance Name
Secondary Insurance ID #
Secondary Insurance Group #"
Insuree"
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