{"id":261,"date":"2021-01-15T18:47:49","date_gmt":"2021-01-15T23:47:49","guid":{"rendered":"https:\/\/thehearinginstitute.fm1.dev\/hearing-clinic\/patient-forms\/"},"modified":"2023-04-18T12:04:44","modified_gmt":"2023-04-18T16:04:44","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/thehearinginstitute.org\/hearing-clinic\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n

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.<\/p>\n\n\n\n

Patient Billing Procedure Updates<\/h2>\n\n\n\n
Patient Fee Handout<\/a>Download<\/a><\/div>\n\n\n\n

New Patient Forms<\/h2>\n\n\n\n
Integrative Counseling & Wellness New Patient Forms<\/a>Download<\/a><\/div>\n\n\n\n
New Adult Patient:<\/strong>\u00a0All new patients 18 years or older must complete this packet of forms.<\/a>Download<\/a><\/div>\n\n\n\n
New Pediatric Patient:<\/strong> A parent of new patients under the age of 18 must complete this packet of forms.<\/a>Download<\/a><\/div>\n\n\n\n
New Speech Patient<\/a>Download<\/a><\/div>\n\n\n\n

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.<\/p>\n\n\n\n

Test & Evaluation Forms<\/h2>\n\n\n\n
ICW Health Risk Assessment<\/a>Download<\/a><\/div>\n\n\n\n
Medications Form<\/a>Download<\/a><\/div>\n\n\n\n
Distress Thermometer\/Problem List (DTPL)<\/a>Download<\/a><\/div>\n\n\n\n
Telemedicine Consent:<\/strong> For patients scheduling a clinical visit using videoconferencing technology.<\/a>Download<\/a><\/div>\n\n\n\n
Telemedicine Procedures Consent:<\/strong> For patients scheduling a clinical visit using videoconferencing technology.<\/a>Download<\/a><\/div>\n\n\n\n
Vestibular:<\/strong> For patients scheduled for a vestibular, dizziness, vertigo or imbalance assessment.<\/a>Download<\/a><\/div>\n\n\n\n
Cochlear Implant:<\/strong> For patients scheduled for a cochlear implant evaluation.<\/a>Download<\/a><\/div>\n\n\n\n
BAHA:<\/strong> For patients scheduled for a Bone Anchored Hearing Aid assessment.<\/a>Download<\/a><\/div>\n\n\n\n
Tinnitus:<\/strong> For patients scheduled for a tinnitus (ringing in the ears) assessment.<\/a>Download<\/a><\/div>\n\n\n\n
 Enrollment Packet:<\/strong> For patients scheduling for an appointment with our Integrative Counseling & Wellness Clinic.<\/a>Download<\/a><\/div>\n","protected":false},"excerpt":{"rendered":"

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. Patient Billing Procedure Updates New Patient Forms In addition to the new patient forms, if you have an appointment scheduled for any of the below tests or…<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":212,"menu_order":17,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","schema":"","fname":"","lname":"","position":"","credentials":"","placeID":"","no_match":false,"name":"","company":"","review":"","address":"","city":"","state":"","zip":"","lat":"","lng":"","phone1":"","phone2":"","fax":"","mon1":"","mon2":"","tue1":"","tue2":"","wed1":"","wed2":"","thu1":"","thu2":"","fri1":"","fri2":"","sat1":"","sat2":"","sun1":"","sun2":"","hours-note":"","footnotes":""},"service_tags":[],"_links":{"self":[{"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/pages\/261"}],"collection":[{"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/comments?post=261"}],"version-history":[{"count":17,"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/pages\/261\/revisions"}],"predecessor-version":[{"id":10080,"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/pages\/261\/revisions\/10080"}],"up":[{"embeddable":true,"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/pages\/212"}],"wp:attachment":[{"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/media?parent=261"}],"wp:term":[{"taxonomy":"service_tags","embeddable":true,"href":"https:\/\/thehearinginstitute.org\/wp-json\/wp\/v2\/service_tags?post=261"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}