Patient Forms

Each patient needs to fill out a patient information form, health history form, and medication list upon their initial visit. We will also ask you to update a new health history form and medication list prior to every diagnostic test for the Audiologist to review.

Completed forms can be emailed to intake@northlandaudiology.com or faxed to 907.789.5828.

Patient Intake Form

Adult Health History Form    |    Child Health History Form (Ages 0-12)

Current Medication List (Adults)

Other Forms

Notice of Privacy Practices

Release of Healthcare Information to Northland Audiology

Release of Healthcare Information from Northland Audiology