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 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