FORMS

Please print and complete new patient paperwork prior to your appointment.
Patients should arrive 15 minutes prior to their appointment time.
Bring photo ID & insurance cards.
Any referrals needed must be brought to the appointment to avoid rescheduling.

Adult Hearing

If you are coming in for an Adult Hearing Evaluation, please complete the following forms:

New Patient Registration Form

Patient Agreement Form

Lifestyle Questionnaire Form

Assessment by Companion Form

Medication List

Pediatric Hearing

If your child is coming in for a Pediatric Hearing Evaluation, please complete the following forms:
Parents are required to stay with their child throughout the appointment.
If parent not attending, please send completed forms with person bringing child.

New Patient Registration Form

Patient Agreement Form

Medication List

Vertigo & Balance Testing

If you are coming in for a Vertigo & Balance Evaluation, please complete the following forms:

New Patient Registration Form

Patient Agreement Form

Lifestyle Questionnaire Form

Assessment By Companion

Medication List

VNG Instructions and Questionnaire Form

Miscellaneous


HIPPA Information Form

Records Release Form

UPDATE AS OF MONDAY MARCH 23, 2020 

Healthy Hearing and Balance will be closed until Monday April 6 assuming it is safe to re-open at that time.

Many of our patients fall squarely in the most at-risk age range and many also have co-morbidities which may put them at further risk from COVID-19.

Our community is wisely practicing Social Distancing. The goal is to slow down transmission and give the best possible chance for our hospital to handle cases as they occur with the best possible outcome for our loved ones.

We are all in this together!

Please know that we have the deepest regard for each and every one of you and are doing our best to make decisions that will keep you safe and still help you to hear better and feel less dizzy. 

Phones and emails from the website will still be monitored.

Thank you for your continued support and for your understanding.

Nancy Hart, Au.D.

Doctor of Audiology and Owner, Healthy Hearing and Balance