New Patient Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastDOB *Phone *Email *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance Name *Primary Care PhysicianPrimary Care Physician LocationDo you have a history of high blood pressure?YesNoDo you have a history of cancer?YesNoDo you have a history of diabetes?YesNoDo you have a history of chronic ear infections?YesNoDo you have a history of family loss of hearing?YesNoDo you have a history of allergies?YesNoDo you have a history of measles?YesNoDo you have a history of scarlet fever?YesNoDo you have a history of meningitis?YesNoDo you have a history of stroke?YesNoDo you have a history of mumps?YesNoDo you have a history of cardiovascular disease?YesNoDo you have a history of depression?YesNoDo you have a history of anxiety?YesNoDo you have a history of chronic arthritis?YesNoDo you currently smoke?YesNoAny history of ear disease?YesNoHistory of exposure to noise?YesNoHave you ever worn a hearing aid?YesNoHave you noticed a decrease in speech clarity and/or understanding?YesNoAny history of trauma to the head?YesNoDo you have any dizziness, vertigo, or loss of balance? If yes, how often?Do you have any ringing, buzzing, hissing? If yes, how often? In the right, left, or both ears?Recent hospitalizations? *How did you hear about us? Select all that apply: *FacebookGoogle/InternetTVMailerReferralOther Hearing Difficulty Questionnaire How would you rate your hearing quality in the following listening situations? With 1 being Very Poor and 5 being Very Good Quiet (one-on-one conversation) Selected Value: 0 Television Selected Value: 0 of diabetes? left, Outdoor Activities Selected Value: 0 Social Gathering Selected Value: 0 Work Place Selected Value: 0 Telephone Selected Value: 0 HIPAA - Health Insurance Portability and Accountability Act I Grant a LAA Associate to release my protected medical information to the following person/people: Name and RelationshipName and RelationshipName and RelationshipBy signing below, I acknowledge that I had the opportunity to review the Notice of Privacy Practices, provided pursuant to the Health Insurance Portability and Accountability Act of 1996, located on LemmeAudiology.com. Electronic Signature *Submit Click Here to read our full Notice of Privacy Practices Request an Appointment: Request an Appointment | Online Booking
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