New Patient Questionnaire | CarePoint Hearing

First things first

Are you a new or current patient?

New patient — first time with CarePoint Hearing Current patient — I've been seen before

About you

Full name *

Best phone number *

Email address *

Best time to reach you

Your goals

Check everything that feels true for you.

Anything else you'd like to improve or share? In your own words — no right or wrong answer.

Your history

Have you had a hearing test in the past 5 years? *

Yes No Not sure

Do you currently wear hearing aids? *

Yes No

Your visit

How would you like to be seen?

I'd prefer you come to my home I'll visit your Goodyear location Either works for me

Are you on Medicare Advantage?

Yes No Not sure

How did you hear about CarePoint Hearing?

Google search Family or friend Facebook Doctor referral Other

Anything else you'd like Melissa to know before your appointment?