Eastside audiology

eastside audiology

162 East 78^th Street, New York, NY 10075

Office Phone: [phone]

Fax: [phone]

[e-mail]
WELCOME TO EASTSIDE AUDIOLOGY
Thank you for contacting us. Your care and privacy is our top priority.
We would appreciate if you would complete the attached forms prior to your visit and bring them with you. Doing so will save you time on the day of your visit. The forms can be filled out by computer or handwritten.
Please bring the following items with you on the day of your visit:
INSURANCE CARD(S) and PHOTO ID
REFERRALS: If a referral is required for insurance purposes, the information will be found on the back of your insurance card. Please arrange to have the appropriate referral prior to your visit. In most cases, it is necessary to obtain the referral from your primary care physician. If you do not have an appropriate referral on the day of your visit, you must make payment in full and receive reimbursement directly from your insurance carrier.
PRIOR TESTS: If you have results from previous examinations, please bring them with you on the day of your visit.
CO-PAYMENTS: Co-payments are due at the time of your visit.
Helpful Hints: Refer to your insurance card for any questions regarding referral information, coverage or co-payments.
If you have any questions, please feel free to call us at [phone] or email us at [e-mail].

We appreciate your choice of Eastside Audiology for your hearing care needs.

We look forward to seeing you at your visit.
Sincerely,
Dr. Ellen Finkelstein, AuD., FAAA

Chief Audiologist

EASTSIDE AUDIOLOGY
Please fill out the following form online and then print and save or forms may be printed and handwritten. To use online form, just tab between various fields.

Bring completed forms on day of visit.

EASTSIDE AUDIOLOGY

162 East 78^th Street, New York, NY 10075

[phone]

patient REGISTRATION FORM

Today’s date:

Home Phone: ( )

PATIENT INFORMATION

Patient’s last name:

First:

Middle:

 Mr.  Mrs.

 Miss  Ms.

Marital status (circle one)

Single / Mar / Div / Sep / Wid

Is this your legal name?

If not, what is your legal name?

Social Security No:

Birth date:

Age:

Sex:

 Yes

 No

/ /

 M

 F

Street address:

Cell Phone No:

Email Address:

( )

POBox:

City:

State:

Zip Code:

Occupation:

Employer Name & Address:

Employer phone no.:

( )

How would you like us to contact you (Home phone, Cell phone, Email)

Who may we thank for referring you?

In case of emergency who should be notified (Name & Phone):

Primary Care Physician (Name & Phone):

PRIMARY INSURANCE INFORMATION

Person Responsible For Bill:

Relation to Patient:

Social Security Number:

Birth date:

Address (if different from patient):

Home phone no.:

/ /

( )

Occupation:

Employer:

Employer address:

Employer phone no.:

( )

Is this patient covered by insurance?

 Yes

 No

Primary Insurance Company:

Patient’s relationship to subscriber:

 Self

 Spouse

 Child

 Other

Subscriber’s name:

Group no.:

Policy no.:

RELEASE OF INFORMATION AND PAYMENT GUARANTEe

The undersigned hereby authorizes the release of any information relating to all claims for benefits on behalf of myself and/or my dependents. I further expressly agree and acknowledge that my signature authorizes EASTSIDE AUDIOLOGY to submit claims for benefits rendered. I understand that I am financially responsible for all charges incurred and understand that any insurance benefits paid will be credited to my account in accordance with the above assignment. I authorize release of information to my insurance company, to my physician, and to the following other parties, with the reasons noted.


Subscriber Signature:____________________________________________________Date__________________________
I have received a copy of Eastside Audiology Notice of Privacy Practices
Signature of Patient/Guardian:____________________________________________ Date__________________________
EASTSIDE AUDIOLOGY 162 East 78^th Street, New York, NY 10075 [phone]
DIZZINESS/IMBALANCE: (IF NONE, GO TO NEXT SECTION):
Lightheadedness _ ____Yes _____No

Swimming Sensation in the head ____Yes _____No

Objects or you spinning ____Yes _____No

Loss of balance when walking-veering to ____Right _____Left

Tendency to fall _____Right _____Left _____Forward ____Back

Blacking out ____Yes _____No

Loss of consciousness ____Yes _____No

Nausea and/or vomiting ____Yes _____No

Headache ____Yes _____No
When did your dizziness first occur?

Do you know of any possible cause of your dizziness?

Were you exposed to any irritating fumes, paints, etc. at onset of the dizziness?


Have you ever injured your head? ______Yes _____No
How often do attacks occur?
Is your dizziness constant or does it come in attacks?

Can you tell when an attack is about to start?

Does change in position make you dizzy?

When you are dizzy, can you stand unsupported? _____Yes _____No

ABOUT YOUR HEARING:
Do you have any of the following symptoms:
Difficulty in hearing? _____NO ___BOTH EARS _____RIGHT _____LEFT
Noise in your ears? ____NO ____BOTH EARS _____RIGHT _____LEFT
Pain in your ears? _____NO ____BOTH EARS _____RIGHT _____LEFT
Fullness or stuffiness in your ears: _____NO ____BOTH EARS ____RIGHT _____LEFT
If yes, does this change in any way when you are dizzy? ____YES ________NO

EASTSIDE AUDIOLOGY 162 East 78^th Street, New York, NY 10075 [phone]
Drainage from your ears? _____NO _____BOTH EARS _____RIGHT _____LEFT
Have you had a previous hearing examination: ________YES ________NO
If yes, where was it performed and by whom:


Do you have any history with hearing aids? ________YES ________NO
If yes, please provide brief details:


Have you experienced any of the following symptoms:
Double/blurred vision or blindness? _______YES ______NO
Numbness of face or extremities? _______YES ______NO
Weakness of arms or legs? _______YES ______NO
Clumsiness of arms or legs? _______YES ______NO
Confusion? _______YES ______NO

OTHER IMPORTANT FACTORS:
Significant Medical Problems:

Medications:

Surgeries:

Is there anything else you would like to share regarding your health?