ACNA Demographic Intake Form

Demographic Intake Form
Date:*

MonthDayYear
Date
PERSONAL INFORMATION
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DO NOT send print mailings
Date of birth:*

MonthDayYear
Date
Personal Health Number:
Email:
example@example.com
Mobile Phone:
Format: (000) 000-0000.
DO NOT textIt's OK to email me messages such as appointment reminders, newsletters and special offers
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
ALTERNATE CONTACT INFORMATION
Name:

First NameLast Name
Is primary contact
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Use alternate contact for billing
Relationship to patient:
Email:
example@example.com
Mobile Phone:
Format: (000) 000-0000.
It's OK to email me messages such as appointment reminders, newsletters and special offers
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
ALTERNATE CONTACT INFORMATION #2
Name:

First NameLast Name
Is primary contact
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Use alternate contact for billing
Relationship to patient:
Email:
example@example.com
Mobile Phone:
Format: (000) 000-0000.
It's OK to email me messages such as appointment reminders, newsletters and special offers
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Address 7807-109 St. NW, Edmonton, AB, T6G 1C6 Email info@acnahearing.com Phone 780.433.4441

Workers’ Compensation Board - Alberta
Claim Number
Veterans’ Affairs Canada
Claim Number
First Canadian Health (NIHB)
Identification number:
Other
Program ID number:
REFERRAL INFORMATION:
Who referred you, or how did you find out about us:
Primary Care Physician:
Clinic Name:
I understand my hearing test results will be available in two weeks
Please Enter Your Initials
I need my test results by:

MonthDayYear
Date
Patient Signature:
LATE ARRIVAL POLICY ACKNOWLEDGMENT
To ensure fairness and quality of care for all clients, appointments will need to be rescheduled if a client arrives more than 15 minutes after their scheduled start time.
I have read and understand the late arrival policy.
CONSENT FOR AI CLINICAL NOTE-TAKING
I consent to the use of the Al-powered clinical note-taking tool during my appointment.I do NOT consent to the use of the Al-powered clinical note-taking tool during my appointment.
Address 7807-109 St. NW, Edmonton, AB, T6G 1C6 Email info@acnahearing.com Phone 780.433.4441

Release Of Information
Audiology Clinic
OF NORTHERN ALBERTA
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.
Signed this*

MonthDayYear
in Edmonton, Alberta
Signed Name:
Printed Name:*
I am unable to digitally sign this document due to current circumstances, however I agree to the information outlined above.
Address 7807 - 109 St. NW, Edmonton, AB, T6G 1C6
Email info@acnahearing.com Phone 780.433.4441

Rows	Yes	Sometimes	No
1. Does your hearing problem cause you to feel embarrassed when meeting new people?
2. Does your hearing problem cause you to feel frustrated when talking to members of your family?
3. Do you have difficulty hearing when someone speaks in a whisper?
4. Do you feel that your hearing problem affects your quality of life?
5. Does your hearing problem cause you difficulty when visiting friends, relatives or neighbors?
6. Does your hearing problem cause you to attend meetings or religious services less often than you would like?
7. Does your hearing problem cause you to have arguments with family members?
8. Does your hearing problem cause you difficulty when listening to the TV or radio at a volume preferred by other listeners?
9. Do you feel that the difficulty with your hearing limits or hampers your personal or social life?
10. Does your hearing problem cause you difficulty when in a restaurant with relatives or friends?

Demographic Intake Form