[ACNA] Adult Intake Form

Title (optional)First NameInitial (optional)Last Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DO NOT send print mailings

Please enter a valid phone number.

TitleFirst NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is primary contactUse alternate contact for billing

Please enter a valid phone number.

TitleFirst NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is primary contactUse alternate contact for billing

Please enter a valid phone number.

I understand my hearing test results will be available
in two weeks(please initial)* I need my test results by:Date*

I, Name* , understand that Audiology Clinic of Northern Alberta will only use personal information that I provide, to serve me with the services that I request. Audiology Clinic of Northern Alberta may share my personal information only with organizations that participate in my care including but not limited to my physician, the manufacturer of my products, and any third party participating in the payment of my products and/or services.

I also understand that Audiology Clinic of Northern Alberta abides by Alberta’s privacy laws and regulations and has a privacy policy that I can request.
I therefore give consent to Audiology Clinic of Northern Alberta to responsibly use my personal information to contact me and share with others only as required to serve my needs.

SignedDay* day ofMonth* , 20Year* :

1 is No Difficulty, 10 is Extremely Difficulty

The purpose of this questionnaire is to identify the problems your hearing loss may (or may not) be causing you. Select Yes, Sometimes or No for each question. Please do not skip a question if you avoid a situation because of a hearing problem

Personal Information

Alternate Contact Information #1

Alternate Contact Information #2

Third Party Information

Referral Information

Release of Information

Case History

Screener