Skip to content
Facebook
1-855-302-5353
Toggle navigation
About
Services
Resources
Events
Contact
Become A Patient
1-855-302-5353
hearing-icon
Become A Patient
Download Patient Intake Sheet (PDF)
Patient Intake
Fill out the info below if you're interested in becoming a patient of the Algoma Hearing Centre.
Name
*
First
Last
Phone
*
Email
*
Preferred Method of Contact
*
Any
Phone
Email
How would you like us to get in touch with you?
Date of Birth
*
Address
*
Street Address
Address Line 2
City
ZIP / Postal Code
Health Card #
*
Insurance
DVA
WSIB
FNA
Private
Insurance #
Medical History
Ear Specialist
Family Doctor
Ear Specialist
Family Doctor
Referral given
Yes
No
Otologic History
Ear Infections / Disease
Ear Pain / Discharge
Ear Fullness / Facial Numbness
Dizziness / Imbalance
Ear Surgery(s)
Tinnitus (Ringing in Ears)
Noise Exposure
Hearing Protection Used
Ear Infections / Disease
Ear Pain / Discharge
Left
Right
Ear Fullness / Facial Numbness
Left
Right
Ear Surgery(s)
Ear Surgery(s)
Left
Right
Tinnitus (Ringing in Ears)
Tinnitus (Ringing in Ears)
Left
Right
Noise Exposure
Military
Industrial
Recreational
Phone
This field is for validation purposes and should be left unchanged.