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Patient Registration Form

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Price: $199.00
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Description
This is a patient intake/registration document. This two-page document includes the most needed information including: patient demographics, marketing tracking, requested disclosures, problem pertinent case history (including warning signs of ear disease and basic audiologic and hearing aid information), current medications, financial policy acknowledgement, HIPAA marketing authorization and HIPAA Notice of Privacy Practices acknowledgement. This form is in a Word format.

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446 East High Street, Suite 10
Lexington, KY 40507
(866) 493-5544
info@audiologist.org

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