Intake Form – Rogue Hearing

PATIENT DETAILS

Patient Name

First

Last

Date of Birth

Sex

Marital Status

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How Can We Contact You? (Check All That Apply)

Opt-in to Recieving Text Messages
Opt-in to Recieving Phone Back
Opt-in to Recieving Emails

Email

Home Phone Number

Work Phone

Cell Phone Number

Opt In to Text (SMS) Messaging

I Opt In to Text (SMS) Messaging
I Decline to Text (SMS) Messaging

By providing a telephone number and checking “Opt-in to Text Messages”, I consent to be contacted by SMS text messages regarding customer care, account notifications, and delivery notifications. Reply STOP to opt-out of further messaging. Reply HELP for more information. Message frequency may vary. Message and data rates may apply. I agree with the Privacy Policy and Terms and Conditions of Rogue Hearing.

Can We Leave a Message?

Home
Cell
Work
Emergency Contact

Please tick all that apply

Patient Current or Previous Occupation

Reason For Appointment

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name

First

Last

Contact Number

Relation to Patient

Referring Physician

Current Healthcare Provider

May We Send Them Information?

Healthcare Provider Contact Information

Please add a contact phone number and email address

INSURANCE PROVIDER

Are You Intending To Use Insurance?

Group Number

ID Number

Subscriber

Employer

Date of Birth

Questions You Work

#SS

About Your Hearing

Are You Having Difficulty Hearing?

Are You Hearing Noise (ex. ringing, clicking, static)?

Are You Having Pain in Ears?

Is There Any Ear Drainage?

Are You Experiencing Fullness or Stuffiness?

Are You Experiencing Dizziness or Balance Problems?

Have You Had a Previous Hearing Exam?

Previous Exam Ptrovider?

Worn Hearing Aids Before?

Provide Previous Hearing Aid Details

Mark All That Apply

What Would You Say Is The Main Reason You Chose Rogue Hearing?

Additional Questions or Comments