Patient Forms 2018-03-06T09:50:45+00:00

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 Information

Adult Health History     |     Child Health History (Newborn-12 years old)

Current Medication List

Other Forms

Notice of Privacy Practices

Release of Information to Northland Audiology & Hearing Services

Release of Information from Northland Audiology & Hearing Services