New Patient Information Record Please Print Neatly!

1. New Patient Information Record Please Print Neatly! Patient Name _____________________________________________ E-mail _________________________________ Age __________ DOB _________________ Gender: □M □F Marital Status: □M □S □W □D □SEP Address ________________________________________ City ____________________ State________ Zip _________ Home Phone Number _____________________________ Cell Phone # ______________________________________ Employer ___________________________________ Occupation ____________________ Phone # _______________ Work Address ___________________________________ City _____________________ State _______ Zip _________ Name of Spouse (Parent if Minor) _________________________________________________ DOB _______________ Emergency Contact ______________________________ Phone # _____________________ Cell # ________________ *Primary Insurance Company __________________________________ *Phone # _____________________________ *Address _______________________________________ City _____________________ State _______ Zip _________ *Name of Insured __________________________________ *ID# ____________________ Group # _______________ *Secondary Insurance Company ________________________________ *Phone # _____________________________ Address ________________________________________ City _____________________ State _______ Zip _________ Named of Insured __________________________________ *ID# ____________________ Group # _______________ Regardless of any insurance coverage that you may have, it is your responsibility to pay your bill. Payment is expected when services are rendered unless other arrangements have been made. We accept cash, check, VISA, Mastercard and Discover. Primary Care Doctor’s Name: _____________________________________________ Phone # ___________________ Address ________________________________________ City _____________________ State _______ Zip ________ Did anyone refer you here? □ Yes □ No If yes, who? ___________________________________________________ How did you hear about our office? □Internet □TV □Radio □Newspaper Ad □Direct Mail □Yellow Pages □Referral (physician/family/friend) □Other (please specify) _____________________________________________ I authorize the release of any medical or other information listed on this form that’s necessary to process this claim. I also request payment of government benefits to either myself or to the party that accepts the assignment. Signature ____________________________________________________ Date _______________________________ *ALL INSURANCE INFO MUST BE COMPLETED* PLEASE TURN OVER AND COMPLETE SECOND SIDE

2. HEARING PROBLEMS Do you currently have any hearing or ear problems? If yes, please be specific. __________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________ MEDICAL PROBLEMS Do you have any current health problems? If yes, please explain briefly. _______________________________________ _________________________________________________________________________________________________ Are you under a physician’s care? □ Yes □No For what? _______________________________________________ Do you smoke? □ Yes □ No Are you pregnant? □ Yes □ No Please list any medications that you are currently taking: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Please check any of the following you’ve had in the past or currently: Are you allergic to any medications or substances? If yes, please list. _________________________________________ ________________________________________________________________________________________________ Is there any other medical information we should know about? _____________________________________________ ________________________________________________________________________________________________