Patient Forms

Patient Intake Form

This form will be completed at your first appointment.  You can fill out the form before your appointment if you wish by downloading from the link above.

Patient History

This form helps collect patient hearing and medical history.

Characteristics of Amplification Tool

This form helps us to better understand your amplification needs.  You can fill out the form before your appointment if you wish by downloading from the link above.

Notice of Privacy Practices

(Read)

This describes our clinic's privacy practices and informs you of your rights regarding your personal health information.  

Notice of Privacy Practices

(Receipt Acknowledgment)

This form acknowledges receipt of our Notice of Privacy Practices and authorizes consent to communicate with individuals listed.

Appointment

& Financial Policies

This form explains our Appointment and Financial policies.