Patient Forms | Heuser Hearing Institute

Please download, complete, and print the forms below that pertain to your appointment and bring them, along with your insurance card, to your first appointment, tests or evaluations.

New Patient Forms

New Adult Patient: All new patients 18 years or older must complete this packet of forms.
New Pediatric Patient: A parent of new patients under the age of 18 must complete this packet of forms.
New Speech Patient

In addition to the new patient forms, if you have an appointment scheduled for any of the below tests or evaluations, please download, complete and bring them with you to your appointment.

Test & Evaluation Forms

Telemedicine Consent: For patients scheduling a clinical visit using videoconferencing technology.
Telemedicine Procedures Consent: For patients scheduling a clinical visit using videoconferencing technology.
Vestibular: For patients scheduled for a vestibular, dizziness, vertigo or imbalance assessment.
Cochlear Implant: For patients scheduled for a cochlear implant evaluation.
BAHA: For patients scheduled for a Bone Anchored Hearing Aid assessment.
Tinnitus: For patients scheduled for a tinnitus (ringing in the ears) assessment.
Enrollment Packet: For patients scheduling for an appointment with our Integrative Counseling & Wellness Clinic.