Patient Forms

Please download and complete the first four patient forms before your initial visit. Our forms are available as PDF downloads. If you don’t have Adobe Acrobat, you can download it by clicking here.

Forms for your initial appointment

Patient Intake Form

Tinnitus + Hearing Health History

For Tinnitus Patients

Records Release Authorization

Notice of Privacy Practices

The Balance Center at NWH+T

Dizziness Questionnaire

Balance Evaluation Instructions

Dizziness Handicap Inventory

Referral Forms for Providers

Patient Referral Form – printable

Patient Referral Form – online submission