PATIENT INTAKE FORM

This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). What this means is the data that you enter here is secure and will only be seen by the practice you intend to send it to.

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

Personal Information

First Name: Middle Initial:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Phone Number:
Email Address:
Gender: MaleFemale
Birthday:
Social Security Number:
Marital Status: SingleMarried
Current Occupation:
Emergency Contact Name:
Emergency Contact Phone:
Emergency Contact Relationship:
Referred By:
Referring Physician:

About Your Hearing

Do you have any of the following symptoms?
Difficulty in hearing: No Both Left Right
Noise in hearing: No Both Left Right
Pain in hearing: 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
Worn hearing aids before?: Yes No

Financial Information

Cash or insurance?:
Primary Insurance
Insurance Name:
Insurance ID #:
Insurance Group #:
Primary Subscribers Name:
Secondary Insurance
Insurance Name:
Insurance ID #:
Insurance Group #:
Secondary Subscribers Name: