Patient Custom Ear Impression Form Musician Monitors of NY

Date

First Middle and Last Name

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Daytime Phone

Cell Phone

Email

Gender

Date of Birth

Referral Source

Do you have ringing in your ears?

YesNo

Do you have a history of drainage from your ear canals?

YesNo

Have you had any ear surgeries?

YesNoOption 3

Have you ever had an evaluation of your hearing?

YesNo

If yes, when?

Have you ever had impression taken of your ears?

YesNo

If yes, when and any details that are important.

Although Maximum care and effort will be taken during the impression process, I understand that the taking of custom ear impression can involve a risk of damage an temporary discomfort to the ear canal. I agree to inform the audiologist of an issue that may arise prior, during and after the impression taking procedure so it can be addressed before i leave the office i acknowledge that all my questions and concerns have been answered to my satisfaction. PLEASE INITIAL THAT YOU HAVE READ THIS.

Client Signature

Dominick Servedio, AuD Signature

CUSTOM EAR IMPRESSION FORM

Verification