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Patient Custom Ear Impression Form Musician Monitors of NY
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Patient Custom Ear Impression Form Musician Monitors of NY
domsears14
2020-06-15T15:19:17-04:00
CUSTOM EAR IMPRESSION FORM
Date
First Middle and Last Name
Address
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
Daytime Phone
Cell Phone
Email
Gender
Date of Birth
Referral Source
Do you have ringing in your ears?
Yes
No
Do you have a history of drainage from your ear canals?
Yes
No
Have you had any ear surgeries?
Yes
No
Option 3
Have you ever had an evaluation of your hearing?
Yes
No
If yes, when?
Have you ever had impression taken of your ears?
Yes
No
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
Verification
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