Patient Forms Posted on January 5, 2021 by Center for Neurosciences Adult Forms Pediatric Forms Ear & Hearing Forms Adult Forms Adult Welcome Letter Adult Patient History Consent for Treatment MRI, CT and X-Ray Information HIPAA Privacy Statement Authorization for Release of Medical Information HIPAA Privacy Authorization Form COVID-19 Memorandum to Patients Pediatric Forms Pediatric Welcome Letter Pediatric Patient History Consent for Treatment MRI, CT and X-Ray Information HIPAA Privacy Statement Authorization for Release of Medical Information HIPAA Privacy Authorization Form COVID-19 Memorandum to Patients Ear & Hearing Forms Consent Forms Office Intake Forms OR Data Forms Post-Operative Instructions Private Pay Surgical Procedures Audiology Protocols COVID-19 Memorandum to Patients Dr. Jacob New Patient Letter Dr. Jacob Cancellation Policy TMC Surgery Scheduling Order Form Preoperative Instructions Preoperative Instructions Spanish Preparing for Vestibular Testing Dr. Jacob Call Coverage Cochlear Implant Vaccination Information Cochlear Implant Vaccination Information Spanish Consent Forms Ear Surgery General Consent Form Ear Surgery General Consent Form Spanish Envoy Esteem Consent Form Envoy Esteem Consent Form Spanish Facial Nerve Decompression/Nerve Graft Consent Form Facial Nerve Decompression/Nerve Graft Consent Form Spanish Gentamicin Injection Consent Form Gentamicin Injection Consent Form Spanish Middle Fossa Surgery Consent Form Middle Fossa Surgery Consent Form Spanish Myringtomy and Tubes Consent Form Myringtomy and Tubes Consent Form Spanish Removal of Facial Cyst Consent Form Resection of Skull Base Tumors Consent Form Resection of Skull Base Tumors Consent Form Spanish Stapedectomy Consent Form Stapedectomy Consent Form Spanish Steroid Injection Consent Form Office Intake Forms Ear and Hearing Adult New Patient Intake Form Ear and Hearing Established Patient Intake Form Ear and Hearing New Pediatric Patient Intake Form OR Data Forms BTI Data Sheet Chronic Ear Data Sheet Hearing Implant Data Sheet Neurotology Data Sheet Stapes and Middle Ear Data Sheet Post-Operative Instructions Attract System Bone Anchored Hearing Implant Post-Operative Instructions Bone Anchored Hearing Implants with Magnetic Coupling Post-Operative Instructions Chronic Ear Surgery Post-Operative Instructions Cochlear Implantation Post-Operative Instructions Cochlear Implantation Post-Operative Instructions Spanish Direct Connect Bone Anchored Hearing Implants Post-Operative Instructions Direct Connect Bone Anchored Hearing Implants Post-Operative Instructions Spanish Ear Tube Post-Operative Instructions Endolymphatic Sac Post-Operative Instructions Endolymphatic Sac Post-Operative Instructions Spanish Esteem Processor/Battery Change Post-Operative Instructions Esteem Processor/Battery Change Post-Operative Instructions Spanish Instructions for Ear Irrigations Middle Fossa Surgery Post-Operative Instructions Middle Fossa Surgery Post-Operative Instructions Spanish Petrosectomy with Ear Closure Post-Operative Instructions Petrosectomy with Ear Closure Post-Operative Instructions Spanish Petrosectomy/Ear Closure/Cochlear Implantation Post-Operative Instructions Skull Base Surgery Post-Operative Instructions Stapedectomy Post-Operative Instructions Surgical Labyrinthectomy Post-Operative Instructions Tonsillectomy/Adenoidectomy Post-Operative Instructions Private Pay Surgical Procedures envoy esteem battery processor change letter 2023 envoy esteem new implant letter 2023 envoy esteem new implant letter spanish 06-2022 ototronix maxum new implant letter 2023 osia system private pay letter 2023 baha attract system private pay letter 06-2022 baha connect system private pay letter 2023 baha connect system private pay letter spanish 06-2022 Audiology Protocols Audiology Welcome Letter Audiologic Evaluation Auditory Training Resources for Cochlear Implant Recipients Bone Anchored Hearing Implant Chemotherapy (Ototoxicity) Surveillance Cochlear Implant Candidacy Cochlear Implant Programming Protocol Hearing Aid Vestibular Evaluation Vestibular Testing Preparation