PATIENT FORMS

Patient Forms Policy: All required forms must be completed prior to your appointment. If you are unable to complete them prior to your appointment, you must arrive 30 minutes prior to your appointment to complete the forms on our office tablets. If you arrive right at your appointment time and do not have your paperwork filled out, we reserve the right to reschedule your appointment. If you do not have access to a computer, smartphone or tablet, you can call our office at 502-215-3665 and request the paperwork be mailed to you.

New Patient Appointment

• Hearing & Medical Case History Form
• Demographics Form
• Acknowledgement of Financial Policies & Privacy Practices Form

Hearing Aid Consultation Appointment

• Hearing Needs Assessment Form

Tinnitus Evaluation Appointment

• Tinnitus Case History Form
• Tinnitus Handicap Inventory Form

If you have any paperwork that needs to be faxed over to Louisville Family Audiology, or would like us to release your audiology records to another provider, please complete the following form:

• Release of Protected Health Information Form

A copy of our “Notice of Privacy Practices” can be found here:

• Notice of Privacy Policies