{"id":466,"date":"2021-01-05T15:17:36","date_gmt":"2021-01-05T22:17:36","guid":{"rendered":"https:\/\/neurotucson.fm1.dev\/resources\/patient-forms\/"},"modified":"2023-06-06T13:00:24","modified_gmt":"2023-06-06T19:00:24","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/neurotucson.com\/about\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n
\n
Adult Forms<\/a><\/div>\n\n\n\n
Pediatric Forms<\/a><\/div>\n\n\n\n
Ear & Hearing Forms<\/a><\/div>\n<\/div>\n\n\n\n

Adult Forms<\/h2>\n\n\n\n
Adult Welcome Letter<\/a> <\/svg> <\/a><\/div>\n\n\n\n
Adult Patient History<\/a><\/svg><\/a><\/div>\n\n\n\n
Consent for Treatment<\/a><\/svg><\/a><\/div>\n\n\n\n
MRI, CT and X-Ray Information<\/a><\/svg><\/a><\/div>\n\n\n\n
HIPAA Privacy Statement<\/a><\/svg><\/a><\/div>\n\n\n\n
Authorization for Release of Medical Information<\/a><\/svg><\/a><\/div>\n\n\n\n
HIPAA Privacy Authorization Form<\/a><\/svg><\/a><\/div>\n\n\n\n
COVID-19 Memorandum to Patients<\/a><\/svg><\/a><\/div>\n\n\n\n

Pediatric Forms<\/h2>\n\n\n\n
Pediatric Welcome Letter<\/a><\/svg><\/a><\/div>\n\n\n\n
Pediatric Patient History<\/a><\/svg><\/a><\/div>\n\n\n\n
Consent for Treatment<\/a><\/svg><\/a><\/div>\n\n\n\n
MRI, CT and X-Ray Information<\/a><\/svg><\/a><\/div>\n\n\n\n
HIPAA Privacy Statement<\/a><\/svg><\/a><\/div>\n\n\n\n
Authorization for Release of Medical Information<\/a><\/svg><\/a><\/div>\n\n\n\n
HIPAA Privacy Authorization Form<\/a><\/svg><\/a><\/div>\n\n\n\n
COVID-19 Memorandum to Patients<\/a><\/svg><\/a><\/div>\n\n\n\n

Ear & Hearing Forms<\/h2>\n\n\n\n
\n
Consent Forms<\/a><\/div>\n\n\n\n
Office Intake Forms<\/a><\/div>\n\n\n\n
OR Data Forms<\/a><\/div>\n\n\n\n
Post-Operative Instructions<\/a><\/div>\n\n\n\n
Private Pay Surgical Procedures<\/a><\/div>\n\n\n\n
Audiology Protocols<\/a><\/div>\n<\/div>\n\n\n\n
COVID-19 Memorandum to Patients<\/a><\/svg><\/a><\/div>\n\n\n\n
Dr. Jacob New Patient Letter<\/a><\/svg><\/a><\/div>\n\n\n\n
Dr. Jacob Cancellation Policy<\/a><\/svg><\/a><\/div>\n\n\n\n
TMC Surgery Scheduling Order Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Preoperative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Preoperative Instructions Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Preparing for Vestibular Testing<\/a><\/svg><\/a><\/div>\n\n\n\n
Dr. Jacob Call Coverage<\/a><\/svg><\/a><\/div>\n\n\n\n
Cochlear Implant Vaccination Information<\/a><\/svg><\/a><\/div>\n\n\n\n
Cochlear Implant Vaccination Information Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n

Consent Forms<\/h3>\n\n\n\n
Ear Surgery General Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Ear Surgery General Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Envoy Esteem Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Envoy Esteem Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Facial Nerve Decompression\/Nerve Graft Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Facial Nerve Decompression\/Nerve Graft Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Gentamicin Injection Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Gentamicin Injection Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Middle Fossa Surgery Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Middle Fossa Surgery Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Myringtomy and Tubes Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Myringtomy and Tubes Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Removal of Facial Cyst Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Resection of Skull Base Tumors Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Resection of Skull Base Tumors Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Stapedectomy Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Stapedectomy Consent Form Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Steroid Injection Consent Form<\/a><\/svg><\/a><\/div>\n\n\n\n

Office Intake Forms<\/h3>\n\n\n\n
Ear and Hearing Adult New Patient Intake Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Ear and Hearing Established Patient Intake Form<\/a><\/svg><\/a><\/div>\n\n\n\n
Ear and Hearing New Pediatric Patient Intake Form<\/a><\/svg><\/a><\/div>\n\n\n\n

OR Data Forms<\/h3>\n\n\n\n
BTI Data Sheet<\/a><\/svg><\/a><\/div>\n\n\n\n
Chronic Ear Data Sheet<\/a><\/svg><\/a><\/div>\n\n\n\n
Hearing Implant Data Sheet<\/a><\/svg><\/a><\/div>\n\n\n\n
Neurotology Data Sheet<\/a><\/svg><\/a><\/div>\n\n\n\n
Stapes and Middle Ear Data Sheet<\/a><\/svg><\/a><\/div>\n\n\n\n

Post-Operative Instructions<\/h3>\n\n\n\n
Attract System Bone Anchored Hearing Implant Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Bone Anchored Hearing Implants with Magnetic Coupling Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Chronic Ear Surgery Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Cochlear Implantation Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Cochlear Implantation Post-Operative Instructions Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Direct Connect Bone Anchored Hearing Implants Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Direct Connect Bone Anchored Hearing Implants Post-Operative Instructions Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Ear Tube Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Endolymphatic Sac Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Endolymphatic Sac Post-Operative Instructions Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Esteem Processor\/Battery Change Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Esteem Processor\/Battery Change Post-Operative Instructions Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Instructions for Ear Irrigations<\/a><\/svg><\/a><\/div>\n\n\n\n
Middle Fossa Surgery Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Middle Fossa Surgery Post-Operative Instructions Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Petrosectomy with Ear Closure Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Petrosectomy with Ear Closure Post-Operative Instructions Spanish<\/a><\/svg><\/a><\/div>\n\n\n\n
Petrosectomy\/Ear Closure\/Cochlear Implantation Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Skull Base Surgery Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Stapedectomy Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Surgical Labyrinthectomy Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n
Tonsillectomy\/Adenoidectomy Post-Operative Instructions<\/a><\/svg><\/a><\/div>\n\n\n\n

Private Pay Surgical Procedures<\/h3>\n\n\n\n
envoy esteem battery processor change letter 2023<\/a><\/svg><\/a><\/div>\n\n\n\n
envoy esteem new implant letter 2023<\/a><\/svg><\/a><\/div>\n\n\n\n
envoy esteem new implant letter spanish 06-2022<\/a><\/svg><\/a><\/div>\n\n\n\n
ototronix maxum new implant letter 2023<\/a><\/svg><\/a><\/div>\n\n\n\n
osia system private pay letter 2023<\/a><\/svg><\/a><\/div>\n\n\n\n
baha attract system private pay letter 06-2022<\/a><\/svg><\/a><\/div>\n\n\n\n
baha connect system private pay letter 2023<\/a><\/svg><\/a><\/div>\n\n\n\n
baha connect system private pay letter spanish 06-2022<\/a><\/svg><\/a><\/div>\n\n\n\n

Audiology Protocols<\/h3>\n\n\n\n
Audiology Welcome Letter<\/a><\/svg><\/a><\/div>\n\n\n\n
Audiologic Evaluation<\/a><\/svg><\/a><\/div>\n\n\n\n
Auditory Training Resources for Cochlear Implant Recipients<\/a><\/svg><\/a><\/div>\n\n\n\n
Bone Anchored Hearing Implant<\/a><\/svg><\/a><\/div>\n\n\n\n
Chemotherapy (Ototoxicity) Surveillance<\/a><\/svg><\/a><\/div>\n\n\n\n
Cochlear Implant Candidacy<\/a><\/svg><\/a><\/div>\n\n\n\n
Cochlear Implant Programming Protocol<\/a><\/svg><\/a><\/div>\n\n\n\n
Hearing Aid<\/a><\/svg><\/a><\/div>\n\n\n\n
Vestibular Evaluation<\/a><\/svg><\/a><\/div>\n\n\n\n
Vestibular Testing Preparation<\/a><\/svg><\/a><\/div>\n\n\n\n

<\/p>\n","protected":false},"excerpt":{"rendered":"

Adult Forms Pediatric Forms Ear & Hearing Forms Consent Forms Office Intake Forms OR Data Forms Post-Operative Instructions Private Pay Surgical Procedures Audiology Protocols<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":111,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"page_no-sidebar.php","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","schema":"","fname":"","lname":"","position":"","credentials":"","placeID":"","no_match":false,"name":"","company":"","review":"","address":"","city":"","state":"","zip":"","lat":"","lng":"","phone1":"","phone2":"","fax":"","mon1":"","mon2":"","tue1":"","tue2":"","wed1":"","wed2":"","thu1":"","thu2":"","fri1":"","fri2":"","sat1":"","sat2":"","sun1":"","sun2":"","hours-note":"","footnotes":""},"service_tags":[],"_links":{"self":[{"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/pages\/466"}],"collection":[{"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/comments?post=466"}],"version-history":[{"count":127,"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/pages\/466\/revisions"}],"predecessor-version":[{"id":2844,"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/pages\/466\/revisions\/2844"}],"up":[{"embeddable":true,"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/pages\/111"}],"wp:attachment":[{"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/media?parent=466"}],"wp:term":[{"taxonomy":"service_tags","embeddable":true,"href":"https:\/\/neurotucson.com\/wp-json\/wp\/v2\/service_tags?post=466"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}