There are three (3) sections within this patient form:

• the patient registration form (2 pages),
• the ambulatory history form
• the financial policy form

• Click here to download and save the file to your desktop
• After it downloads, open the file
• Input your information in the shaded areas
• For "Yes/No" boxes, click on the appropriate box and a check mark will appear. 
• Shortcut tip: Use the Tab key to move on to the next shaded area
• Once you have completed the form, save it
• Send the form to us via email as an attachment

• When the form is completed, send it via email as an attachment
• If the form is for Dr. Peters, email it to Elida Garcia
• If the form is for Dr. Dansby, email it to Helen Beasley
• If the form is for the Audiology Department, email it to Barbara Godfrey
   

Prior to the appointment

• Please confirm your forms have been received by email or fax
• NOTE: When you come in, we will have the forms ready for you to sign
• NOTE: if you are coming in for an ABR or a VNG test, please click on either one to read instructions.
• NOTE: if you have an appointment with the audiology lab, please go to Suite A-107.