BCPL Hearing Screening Consent Form

Baltimore County Department of Health

Audiology Program
Patient Consent 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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If the parent/legal guardian will not be bringing the child to their upcoming Audiology appointment, please list the approved individual(s) that are allowed to accompany the child to their visit.
Patient Demographics
Gender

Other
Race
Ethnicity
Primary Language

Other
Would you like an interpreter?
Hearing Questions
Are there any hearing concerns? If yes, please describe.
Did your child pass the Newborn Hearing Screening in both ears?
Should be Empty:

Baltimore County Department of Health