Patient Forms – NYC Hearing Associates

Patient Intake Form

To our new patients, please fill out the online patient intake form below. If you prefer, you can download the printable version of the form, fill out and fax to our office at (212) 354-2364. Thank you.

Download Printable Version

Personal Information

First Name

Middle Initial

Last Name

Date of Birth

Social Security Number

Employer

Gender

Marital Status

Contact Information

Home Phone

Work Phone

Cell Phone

Email Address

Address

City

State

Zip Code

Emergency Contact

Emergency Contact Name

Contact Relationship

Contact Phone

Your Physician

Primary Care Physician

Physician Phone

Would you like us to send a report of our audiological findings to your physician?

Reason for Visit Referral Source (i.e. Physician, Google)

Privacy Practice Notice

According to government law, we are required to make available to you a copy of our privacy practice notice.
Your signature below acknowledges your receipt of this notice:

Signature

Date