Medium

Available on

Apple Android Windows

Hearing Clinic Client Intake Form Mobile App

Hearing Clinic Client Intake Form mobile application is for gathering client information for a clinic. Application will ask for the customers basic information and will ask personal questions on their conditions with a signature consent for the patient privacy protection. This is a great app if you doing anything with speech-language pathologist, hearing loss, hearing aid, hearing impairment, speech and hearing impairment.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Hearing Clinic Client Intake Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Name: Mr/Mrs/Ms/Dr

  • Ico date

    Birth Date

  • Ico multiline

    Address:

  • Ico textbox

    City/town:

  • Ico integer

    Postal Code:

  • Ico textbox

    Home Phone

  • Ico textbox

    Cell Phone

  • Ico textbox

    Work Phone

  • Ico textbox

    Occupation (or Previous if retired):

  • Ico textbox

    Email

  • Ico textbox

    Physician's Name:

  • Ico textbox

    Physicians Town/City:

  • Ico textbox

    How did you hear about Resonance Hearing Clinic?

  • Ico statictext

    I understand the personal information gathered on this form and in subsequent testing will be kep...

  • Ico signature

    Patient Signature:

  • Ico textbox

    Please fist who should receive a copy of your hearing test results:

  • Ico textbox

    What hobbies or activities do you participate?

  • Ico dropdown

    Who is most concerned about your hearing?

  • Ico textbox

    When did you first notice a hearing problem?

  • Ico dropdown

    Has it become worse recently?

  • Ico dropdown

    Do you hear better in your:

  • Ico dropdown

    Have you been exposed to loud noise?

  • Ico dropdown

    Do you have armed forces experience?

  • Ico dropdown

    Have you been exposed to noise at work?

  • Ico textbox

    Do you have any noises in your ears (e.

  • Ico textbox

    What serious illnesses have you had?

  • Ico textbox

    What medications are you taking?

  • Ico dropdown

    Do you experience:

  • ...and More!

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