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  • Text Message: (289) 356-6010
  • 118 King Avenue East, Newcastle, Ontario
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    • Ear Protection
    • Earwax Removal
    • Hearing Aids
    • Hearing Tests
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Contact Us

Intake Form

Intake Form

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Patient Information

Street Address(Required)
MM slash DD slash YYYY
(If required by office, may need at appointment)
Primary Contact for appointments (if other please fill out name, relationship and phone number)

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:

Case History Information

Do you feel you have hearing loss(Required)
Do you have or have you ever experienced any of the following?<br /> (Please check all that apply)
Prior use of Hearing Aids?
If you've used hearing aids are you satisfied with them?

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

Consent(Required)
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.
  • Home
  • Our Team
  • Blog
  • Intake Form
  • Contact Us
  • Home
  • Our Team
  • Blog
  • 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.

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