Helping Pennsylvania Hear With Two Locations

We Have Locations in Clarks Summit and Tunkhannock

(570) 587-EARS(3277)

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We Want to Work with You to Improve Your Hearing and the Quality of Your Life

Patient Forms

Download and print the necessary forms before your appointment.

Adult History

Balance History Page 1
Balance History Page 2

Consent for Treatment

Patient Information Sheet

Pediatric History

Permission for Verbal Communication with Family and Friends

Tinnitus Functional Index Page 1
Tinnitus Functional Index Page 2
Tinnitus Functional Index Page 3
Tinnitus Functional Index Page 4
Tinnitus Functional Index Page 5

Tinnitus Reaction Questionnaire

Bekesy Tinnitus