Swim Molds

Date*

MonthDayYear
Date
Time: include am or pm*
Patients Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Patient/Guardian Name (if patient is a child):

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Alternate Email
example@example.com
I AUTHORIZE ALL ABOUT HEARING INC.:

· To perform all recommended/referred diagnostic procedure.

· To complete all measures needed to make a diagnosis and recommendation.

· To release such diagnostic material to third-party payors and /or other health professionals
Patient Signature*

Clear
Date*

MonthDayYear
Date
Medical History
Have you experienced any pain or discomfort in the ear?*

YesNo
If yes, which ear?

LeftRightBoth
Sudden or rapidly changing hearing loss within the last 90 days?*

YesNo
If yes, which ear?

LeftRightBoth
Have you received any medical/surgical treatment on your ears such as tubes?*

YesNo
If yes, which ear?

LeftRightBoth
Have you experienced any acute or chronic dizziness?*

YesNo
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that ALL ABOUT HEARING INC. provided me with a written copy of its Notice of Privacy Practices. I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
Should be Empty:

Medical History