PATIENT INTAKE FORM

First Name: Middle Initial:
Last Name:
Address Line 1:
Address Line 2:
City:
State: Choose your stateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyoming
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: …choose contactMotherFatherWifeHusbandDaughterSonSisterBrotherOther RelativeFriend
Referred By: …choose referrerMotherFatherWifeHusbandDaughterSonSisterBrotherOther RelativeFriend
Referring Physician:

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

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: