Allard Audiology

Welcome to Allard Audiology!

120B Willowdale Ave, North York, ON M2N 4Y2

INFORMED CONSENT
This standard and securely encrypted form will give you the opportunity to grant Allard Audiology consent to collect, store and uses certain personal and medical data specifically for the purpose of providing you the highest standard of care and maintaining contact with you at your discretion. The data referenced above may include your contact information, medical history and the results of any audiology services we perform.

We value your privacy and are committed to protecting your data in line with applicable privacy laws and our clinic's privacy policy. This information will only be used for your direct care and will not be shared with any third parties without your explicit consent, except where required by law.

By clicking yes below, you give your consent for Allard Audiology to collect, store, and use your data for the purpose of providing audiology services.

It's important for you to understand that you have the right to withdraw your consent at any time, without impacting your right to receive care. You are most welcome to ask any clarifying questions you need to in order to feel comfortable signing off on consent.

Do you give your consent for Allard Audiology to collect, store, and use your data for the purpose of providing audiology services.

Yes No

Is this appointment for you or your child?

My self My child

Client Information

First name

Last name

Home Address

Apt/Unit #

City

Postal Code

Date of Birth

Phone number

Cell phone number

Email address (optional)

Would you like to receive promotional emails from us? We send no more than 2 emails a month.

Yes No

Health Card Number

If you do not have please enter N/A

Date of Expiration

If no health card please enter N/A

Family Doctor

Family Dr Phone #

Do we have your consent to share your Audiogram with your family doctor? We may need to send your doctor a copy if there is a need for a follow up. We'll let you know if this is the case

Yes No

Do you have private insurance

Yes No

What insurance company are you with?

Please Provide Group Policy Number

What is your certificate/plan ID #

There are multiple sources of funding available to Canadians, First Nations, Metis and Inuit patients for their hearing needs. If you selected I'm not sure, worry not. Our dedicated audiologist will explore this with you at your hearing test if there is proven to be a need.

Please check any funding source you have (or may have access to)

NIHB (Indigenous patients)

Indigenous Patients

ODSP

Ontario Disabilities Support Program

WSIB

Workers Safety Insurance Board

IFHP

Refugee Claimants with a UCI #

DVA

Veterans

Please provide your case worker name, office and/or phone number

Please provide ODSP #

Please provide us with your NIHB # or Status Card #

Please provide us with your K #

Please provide us your UCI # (on the brown paper)

Please provide us with your WSIB #

Hearing History

Have you ever worn hearing aids?

Yes No

When did you last get hearing aids?

Do you currently have hearing aids?

Yes No

When did you get the hearing aids you currently use?

Have you had your hearing tested before?

Yes No

Please enter the date of the test approximately

Do you find it hard to hear?

Yes No

How long has this been an issue?

Do you find sometimes your hearing is better than others?

Yes No

Please tell us what you think may have caused hearing loss?

Do you have any family who experienced hearing loss when they were under 50 years old?

Yes No

Have you experienced loud noises at a job?

Yes No

Please explain

Have you experienced Tinnitus

Yes No

How long does the Tinnitus last?

Please check all boxes that apply

Speech/language concerns

Educational Concerns

Complications during pregnancy

Premature birth

born with jaundice

born with any abnormalities

complications during labour

Your information will be encrypted.

Allard Audiology

Welcome to Allard Audiology!

Client Information

Hearing History

Welcome to Allard Audiology!

ALLARD AUDIOLOGY