Date of call:

Patient Information
Patient Name: Birthdate:
Patient Address:
City: State: Zip:
Telephone:Alternate Phone:
Work/Cell Telephone:Alternate Phone:

How Did You Hear About Us?
Newspaper Website/Internet   Friend/FamilyReferred (Name)
T.V. Ad Senior Living         DoctorReferral (Name)
Phone Book Received A Letter Other(Please Explain)

Additional Information
Seasonal Address:
City: State: Zip:
(Occasionally we send out important information to our patients. Please include your email-address below:)
E-mail Address:

Physician Information
Name of Family
Physician or ENT:
City: State: Zip:

Hearing Health HistoryYesNoIf Yes, Please List/Describe
Do you ever notice its difficult to understand words clearly? 
Do you have trouble hearing women/children? 
Do people say you have the TV or radio turned up? 
Do you ask people to repeat themselves? 
Do you sometimes feel that people are talking "softly" or mumble? 
Do you have difficulty hearing speech in background noise? 
On a scale from 1-10, one being the worst and 10 being the best, how would you rate your overall hearing ability?
(Select one) 1  2  3  4  5  6  7  8  9  10

Authorization to Release Information: I hereby authorize the release of information contained in my medical record and other related
information, verbal and written, to be shared with my physician or other hearing health care professionals regarding my testing evaluation, treatment, processing of a claim
or to receive authorizations from any insurance or government agency as it relates to my treatment plan.
Trial Period: Woodard Hearing Centers offers a 60-day trial period upon which time a full refund will be honored less the professional service fee and any
custom ear mold charges.
Responsibility for Payment:I understand that I am personally responsible for payment which is due at the time of delivery.