(905) 446-4327
Text Message: (289) 356-6010
118 King Avenue East, Newcastle, Ontario

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Patient Information

Preferred Title(Required)

Full Name(Required)

Please enter preferred title

Street Address(Required)

Street Address Address Line 2 City Province Postal Code

Preferred Phone Number(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Heath Card Number and Version Code

(If required by office, may need at appointment)

Name that appears on Heath Card

Family Doctor's Name(Required)

Family Doctor's office number(Required)

Present/Past Occupation

Primary Contact for appointments (if other please fill out name, relationship and phone number)

Patient

Other

To get a better understanding of who you communicate with on a daily basis, please let us know who resides in the same household with you:

Spouse/Partner

Children

Parent

Roommate

Live Alone

Other

Case History Information

Do you feel you have hearing loss(Required)

Yes, in both ears

Yes, only in my left

Yes, only in my right

How long do you feel you've had hearing loss?(Required)

Have you ever had a hearing test? If yes, when?

Any Present Medications?

Do you have or have you ever experienced any of the following?<br /> (Please check all that apply)

Tinnitus (ringing in the ears)

Ear infections

Ear fullness

Ear surgery

Head injury or trauma

Dizziness or vertigo

Family history of hearing loss

Diabetes

Allergies/Sinus

Use a pace maker

Meningitis

Radiation or chemotherapy

Stroke OR mini stroke

Heart attack

Use of blood thinners

Have you been exposed to loud noise at work? If yes for how long?

Have you seen an Ear, Nose and Throat Specialist? If yes, who?

Prior use of Hearing Aids?

Yes

If you've used hearing aids are you satisfied with them?

Yes

If you could improve something about your current hearing aids, what would it be?

Additional Information

Thank you for choosing Newcastle Hearing Solutions and placing your trust in us. Our goal is to provide superior hearing health care services to patients like you. We value your opinion and would appreciate you taking a moment to answer the following questions.

How did you hear about Newcastle Hearing Solutions

Patient Referral

Family/Friend Referral

Physician Referral

Workplace Referral

Sign On Building

Google

Facebook

Website

Magazine

Newspaper

Other

Consent(Required)

I have read and understand the Privacy Statement below.

Privacy Statement
We understand the importance of privacy to our patients, and are committed to safeguarding your privacy. The information requested on this form will only be used to send you information about our products and services, and will not be rented, sold, or exchanged with any third parties. Once entered into our database, access is strictly controlled and information is kept for the sole purpose of sending out mailings and creating statistical reports. If you would ever like to update your information, or if you ever change your mind and wish to stop receiving information about our products and services, please call us and your information will be updated or deleted from our records.

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Intake Form
Contact Us

Ear Protection
Earwax Removal
Hearing Aids
Hearing Tests

Ear Protection
Earwax Removal
Hearing Aids
Hearing Tests

Newcastle Hearing Solutions Limited is committed to respecting the privacy of individuals and recognizes a need for the appropriate management and protection of any personal information that you agree to provide to us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request.

Patient Information

Case History Information

Additional Information

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