Scheduling Appointment Form Patient Information First Name* Last Name* Email* Date of Birth* Phone Number* Appointment Information Select a Clinic Please select Myrtle Beach, SC - 950 48th Ave N - Suite 203, Myrtle Beach SC 29577 Southport, NC - 4128 Vanessa Dr, Suite C, Southport, NC, 28461 Sunset Beach, NC - 710 Sunset Blvd N Suite D, Sunset Beach, NC 28468 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.