Intake Form

Birth Date (required) *
Please ensure your birthdate follows this format: Year-Month-Day

Gender (required) *
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• Have you had cerumen (wax) removed professionally before?: YesNo

• Are you aware of any pre-existing hearing loss?: YesNo

• Any history of sudden or rapidly progressive or fluctuating hearing loss?: YesNo

• Any history of active drainage activity or bleeding from the ear(s), in the preceding 90 days?: YesNo

• Any ongoing pain or discomfort in the ear?: YesNo

• Do you have tinnitus (sensation of a ringing, roaring, buzzing, or pulsing sound in your ear(s) or head)?: YesNo

• Do you experience acute, recurring episodes, or chronic dizziness or increasing imbalance?: YesNo

• Have you had any ear surgery?: YesNo

• Have you had any significant head trauma?: YesNo

• Are you taking any blood-thinning medications? (ex: Warfarin, Coumadin, Heparin, Aspirin): YesNo

• Do you experience any facial nerve paralysis? Y/N: YesNo

• Do you have any of the following conditions: Diabetes, Heart Disease, Compromised Immunity?: YesNo

How did you hear about us?
WebsiteGoogle searchSocial mediaJyoti/outreachSign/posterDoctorFamily, friends, or word of mouthOther

Testimonial Consent: By checking this box, I grant permission to Surrey Hearing Care to use my feedback and/or review for marketing purposes, including posting on the clinic's website, social media platforms, and other promotional materials. I understand that my first name and last initial may be used unless I request to remain anonymous.

By clicking Submit, I confirm that the information provided above is true and accurate to the best of my knowledge.