New Patient Information

Name and relation of person(s) who will be accompanying you to the appointment *

Would you like a copy of your audiogram sent to your PCP? *

Yes No

How did you hear about us? *

Family or Friend Internet Search Marketing Piece Other

Do you have loss of hearing in one or both ears? *

Left Right Both

Please list any surgeries or medical problems with your ears: *

Do you have any nosies or ringing in your ears? *

Left ear Right ear Both ears No

Have you had any dizziness, or difficulities with your balance within the last 90 days? *

Yes No

PLEASE NOTE:

We ask that you bring a list of all medications to your appointment with you.
If you have had a recent hearing exam, please bring a copy of the test with you for comparison.
If you have a known medical condition that affects your hearing, please bring any recent test results with you.

New patient information