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 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