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Audiology Intake Form

Please complete this Audiology intake form prior to your appointment. This will make your check-in process faster.

Patient Name

Have you ever had a hearing evaluation? Yes/No Where and When?

In which ear is your hearing the worst? Right/Left/Same/Neither

Which ear do you use on the phone? Left/Right/No preference

Have you ever worn or tried hearing aids? Yes/No If yes, Right/Left/Both

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