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Auditory Processing Case History Form

Please note that not all insurances will cover the cost of this testing. Please contact your insurance company for more information regarding coverage. We will bill your insurance for testing; however, you will be responsible for your copay and any applicable non-covered portion.

Results will be sent to names/locations listed below if address or fax number is provided.

I authorize Preferred Audiology Care, LLC to disclose the results of this evaluation to those listed above:

Results will not be available on the day of the evaluation as all results must be analyzed. A report will be ready by 10-14 days after testing is complete. The report will explain the findings and recommendations for school and home. Parents may contact the audiologist who completed the evaluation if they have any questions about the results.

Medical History

Have you ever been diagnosed with any of the following?

*If you answered yes to any of the above, please include copies of professional evaluations/reports.

Educational/Occupational Information:

Do you notice concerns with any of the following?

Please check Yes or No for the following:

Sudden plugged ear sensation? Ringing in your ears? Longterm exposure to loud sounds? Memory Loss? Dizziness? It's time to have your hearing screened. Schedule your free hearing screening now