Scheduling Appointment Form Patient Information First Name* Last Name* Email* Date of Birth* Phone Number* Appointment Information Select a Clinic Please select Alton, IL - 237 A East Center Drive Alton, IL 62002 Arnold, MO - 1511 Astra Way Arnold, MO 63010 Chesterfield, MO - 703 Long Road Crossing Drive Suite 7 Chesterfield, MO 63005 Crestwood, MO - 397 Watson Plaza St. Louis, MO 63126 Crystal City, MO - 2370 N Truman Blvd Crystal City, MO 63019 Cuba, MO - 501 W Washington Blvd. Cuba, MO 65453 Eureka, MO - 98 The Legends Pkwy Suite 105 Eureka, MO 63025 Fairview Heights, IL - 5300 North Illinois Hwy 159 Suite 105 Fairview Heights, IL 62208 Glen Carbon, IL - 4219 IL - 159 Suite 1 Glen Carbon, IL 62034 Hampton, MO - 16 Hampton Village Plaza Suite 290 St. Louis, MO 63109 Highland, IL - 5 Apex Dr. Suite 100 Highland, IL 62249 Joplin, MO - 420 N Rangeline Road Suite 12 Joplin, MO 64801 Lebanon, MO - 281 S. Jefferson Ave. Suite G Lebanon, MO 65536 Manchester, MO - 15864 Manchester Rd. Ellisville, MO 63011 Mid Rivers, MO - 318 Mid Rivers Mall Dr. Suite K St. Peters, MO 63376 O'Fallon, MO - 1102 Tom Ginnever Ave. O'Fallon, MO 63366 Rolla, MO - 830 S. Bishop Ave. Rolla, MO 65401 South County, MO - 9964 Kennerly Rd. Suite B St. Louis, MO 63128 St. Charles, MO - 2151 Bluestone Dr. St. Charles, MO 63303 Sullivan, MO - 102 Progress Pkwy Suite C Sullivan, MO 63080 Troy, MO - 12 The Plaza Troy, MO 63379 Union, MO - 305 N. Hwy 47 Union, MO 63084 Warrenton, MO - 517 Anwijo Way Warrenton, MO 63383 Waterloo, IL - 102 S. Market St. Waterloo, IL 62298 Wentzville, MO - 1830 Wentzville Pkwy Wentzville, MO 63385 West County, MO - 2821 N. Ballas Rd. Suite 100 St. Louis, MO 63131 Clinic Hours Disabled/grayed out time slots are already booked. Patient Screening Form Do you have any of the following? Drainage from the ear? Yes No Deformity of the ear? Yes No Acute or chronic dizziness? Yes No Pain or discomfort in the ear? Yes No Ringing in the ears? Yes No Experienced sudden or rapid hearing loss in the past 90 days? Yes No Ever found it necessary to have a doctor remove wax from your ear? Yes No Do you have any problems in the following situations? Understanding conversations? Yes No Difficulty understanding people if they are not looking at you? Yes No Trouble hearing at movies, concerts, houses of worship, or other public gatherings? Yes No Hearing in a crowd or restaurant? Yes No Hearing on the telephone? Yes No Understanding the TV without closed captioning? Yes No Have loved ones encouraged you to have your hearing checked? Yes No Do you think you currently have a hearing loss? Yes No Unsure Do you currently wear hearing aids? Yes No I have read and agree to the HIPAA, Privacy Practices & Terms and Conditions that follows all state & federal HIPAA laws.
