BCPL Hearing Screening Intake Form

Baltimore County Department of Health

Audiology Program
Patient Intake Form
Today's Date*

MonthDayYear
Name of Person Completing Form*

First NameLast Name
Relation to Patient
Email
example@example.com
Patient Contact Information
Patient's Name*

First NameLast Name
Date-of-Birth*

MonthDayYear
Postal/ Zip Code*

Street Address

Street Address Line 2

CityState / Province
Legal Guardian's Name

First NameLast Name
Consent for Services
I have the legal power to make medical decisions for the above-named patient, documentation of which can be provided upon request, as necessary. I hearby give consent for the above-named patient to be evaluated and/or treated by the audiologist by signing this document.
Signature of Parent/Legal Guardian *

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Patient Demographics
Gender*

MaleFemaleOther
Race*

AsianBlack/African AmericanAlaskan NativeAmerican IndianMulti-racialHawaiian/Pacific IslanderWhite
Ethnicity*

Hispanic/LatinoNon-Hispanic/Non-Latino
Primary Language*

EnglishSpanishOther
Would you like an interpreter?*

YesNo
Hearing Questions
Are there any hearing concerns? If yes, please describe. *
Did your child pass the Newborn Hearing Screening in both ears?*

YesNoNot SureNever had one
Should be Empty:

Baltimore County Department of Health