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PDF-online-form

October 30, 2020
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Today’s date Clinic name Clinic address (PDF: one line, Word: multiple lines) Clinic address (one line) Clinic address (multiple lines) Clinic address and phone number (multiple lines) Clinic name, address and phone number (multiple lines) Clinic street line (unit, street number, and street name) Clinic unit Clinic street number Clinic street name Clinic city Clinic province Clinic postal code Clinic phone number (formatted) Clinic phone number Clinic fax number (formatted) Clinic fax number Clinic email address Clinic website URL Clinic online booking website URL Online booking needs to be enabled Clinic online booking URL (generated URL) Online booking needs to be enabled Online booking URL (generated URL) Online booking needs to be enabled Patient ID number Patient reference number Patient salutation Last name First name Patient full name (last, first) Patient full name (first last) Middle initial Health card Number/SS# Address (full address, multiple lines) Address (full address, one line) Address (unit, street number, and street name) Address (city line) Apt/Unit Street number Street name City Province Postal/Zip code Do not mail (Yes/No) Allow mail (Yes/No) Telephone (home formatted with hyphens) Telephone (home unformatted) Telephone (work) Telephone (work formatted with hyphens) Telephone (work unformatted) Telephone extension (work) Telephone (mobile) Telephone (moblie formatted with hyphens) Telephone (moblie unformatted) Do not text (Yes/No) Allow text (Yes/No) Email address Do not email (Yes/No) Allow email (Yes/No) Do not send commercial messages (Yes/No) Allow commercial messages (Yes/No) Patient note details Patient gender abbreviation Date of birth Age Patient type (audiology tab) Account balance Alternate contact salutation Alternate contact first name Alternate contact last name Alternate contact name (last, first) Alternate contact name (first last) Alternate contact middle initial Alternate contact address (multiple lines) Alternate contact address (one line) Alternate contact address (unit, street number, and street name) Alternate contact address (city line) Alternate contact apt/unit Alternate contact street number Alternate contact street name Alternate contact city Alternate contact province Alternate contact postal/zip code Alternate contact telephone (home) Alternate contact telephone (home formatted with hyphens) Alternate contact telephone (home unformatted) Alternate contact telephone (work) Alternate contact telephone (work formatted with hyphens) Alternate contact telephone (work unformatted) Alternate contact telephone extension (work) Alternate contact telephone (mobile) Alternate contact telephone (mobile formatted with hyphens) Alternate contact telephone (mobile unformatted) Alternate contact do not text (Yes/No) Alternate contact allow text (Yes/No) Alternate contact email address Alternate contact do not email (Yes/No) Alternate contact allow email (Yes/No) Alternate contact relationship Alternate contact bill to contact (Yes/No) Alternate contact primary contact (Yes/No) Referrer type Referral source Contact salutation (Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact first name Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact last name Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact middle initial Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact address (multiple lines) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact address (one line) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact address (unit, street number, and street name) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact address (city line) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact apt/unit Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact street number Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact street name Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact city Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact province Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact postal/zip code Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (home) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (home formatted with hyphens) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (home unformatted) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (work) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (work formatted with hyphens) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (work unformatted) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone extension (work) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (mobile) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (mobile formatted with hyphens) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact telephone (mobile unformatted) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact do not text (Yes/No) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact allow text (Yes/No) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact email address Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact do not email (Yes/No) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. Contact allow email (Yes/No) Contact uses the alternate contact’s information if “Primary contact”, otherwise patient’s information. *Primary Insurer name Only available for US customers. *Primary Insurer address Only available for US customers. *Primary insurer unit Only available for US customers. *Primary insurer street number Only available for US customers. *Primary insurer street name Only available for US customers. *Primary Insurer city Only available for US customers. *Primary Insurer state Only available for US customers. *Primary Insurer country Only available for US customers. *Primary Insurer zip Only available for US customers. *Primary Insurer phone number Only available for US customers. *Primary insurer fax Only available for US customers. *Primary Payer ID# Only available for US customers. *Primary insurance plan Only available for US customers. *Primary ID# Only available for US customers. *Primary name Only available for US customers. *Primary relationship Only available for US customers. *Primary address Only available for US customers. *Primary city Only available for US customers. *Primary country Only available for US customers. *Primary state Only available for US customers. *Primary zip Only available for US customers. *Primary telephone Only available for US customers. *Primary policy # Only available for US customers. *Primary date of birth Only available for US customers. *Primary gender Only available for US customers. *Primary Employer/School name Only available for US customers. *Primary Insurance plan/Program name Only available for US customers. *Primary Insurer Notes Only available for US customers. *Primary Insurer Pre-certified (yes/no) Only available for US customers. *Primary Insurer Hearing Aid Benefit (yes/no) Only available for US customers. *Primary Insurer Estimated Benefit Only available for US customers. *Primary Insurer Deductible Only available for US customers. *Primary Insurer Copay Only available for US customers. *Secondary Insurer name Only available for US customers. *Secondary Insurer address Only available for US customers. *Secondary Insurer unit Only available for US customers. *Secondary Insurer street number Only available for US customers. *Secondary Insurer street name Only available for US customers. *Secondary Insurer city Only available for US customers. *Secondary Insurer state Only available for US customers. *Secondary Insurer country Only available for US customers. *Secondary Insurer zip Only available for US customers. *Secondary Insurer phone number Only available for US customers. *Secondary insurer fax Only available for US customers. *Secondary Payer ID# Only available for US customers. *Secondary insurance plan Only available for US customers. *Secondary ID# Only available for US customers. *Secondary name Only available for US customers. *Secondary relationship Only available for US customers. *Secondary address Only available for US customers. *Secondary city Only available for US customers. *Secondary country Only available for US customers. *Secondary state Only available for US customers. *Secondary zip Only available for US customers. *Secondary telephone Only available for US customers. *Secondary policy # Only available for US customers. *Secondary date of birth Only available for US customers. *Secondary gender Only available for US customers. *Secondary Employer/School name Only available for US customers. *Secondary Insurance plan/ Program name Only available for US customers. *Secondary insurer Notes Only available for US customers. *Secondary Insurer Pre-certified (yes/no) Only available for US customers. *Secondary Insurer Hearing Aid Benefit (yes/no) Only available for US customers. *Secondary Insurer Estimated Benefit Only available for US customers. *Secondary Insurer Deductible Only available for US customers. *Secondary Insurer Copay Only available for US customers. *Marital status Only available for US customers. *Employment status Only available for US customers. Insurer 1 policy number For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 ID number For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 ID number For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 address (multiple lines) For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 street line (unit, street number, and street name) For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 city line (city, province, postal code) For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 unit For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 street number For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 street name For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 city For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 province For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 country For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 postal code For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 telephone For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 telephone (unformatted) For multiple insurers, change 1 to 2, 3, or 4 Insurer 1 fax number For multiple insurers, change 1 to 2, 3, or 4 Patient has Insurer ADP (Yes/No) Only available for CA customers. Insurer ADP policy number Only available for CA customers. Patient has Insurer VAC (Yes/No) Only available for CA customers. Insurer VAC policy number Only available for CA customers. Patient has Insurer WSIB (Yes/No) Only available for CA customers. Insurer WSIB policy number Only available for CA customers. Patient has Insurer NIHB (Yes/No) Only available for CA customers. Insurer NIHB policy number Only available for CA customers. Patient has Insurer RCMP (Yes/No) Only available for CA customers. Insurer RCMP policy number Only available for CA customers. Patient has Insurer WCB AB (Yes/No) Only available for CA customers. Insurer WCB AB policy number Only available for CA customers. Patient has Insurer WCB BC (Yes/No) Only available for CA customers. Insurer WCB BC policy number Only available for CA customers. Patient has Insurer WCB MB (Yes/No) Only available for CA customers. Insurer WCB MB policy number Only available for CA customers. Patient has Insurer WCB SK (Yes/No) Only available for CA customers. Insurer WCB SK policy number Only available for CA customers. Patient has Insurer WCB NWT (Yes/No) Only available for CA customers. Insurer WCB NWT policy number Only available for CA customers. Patient has Insurer WCB NB (Yes/No) Only available for CA customers. Insurer WCB NB policy number Only available for CA customers. Patient has Insurer WCB NS (Yes/No) Only available for CA customers. Insurer WCB NS policy number Only available for CA customers. Patient has Insurer AADL (Yes/No) Only available for CA customers. Insurer AADL policy number Only available for CA customers. Patient has Insurer WCB NL (Yes/No) Only available for CA customers. Insurer WCB NL policy number Only available for CA customers. Patient has Insurer CNESST (Yes/No) Only available for CA customers. Insurer CNESST policy number Only available for CA customers. Patient has Insurer WCB PEI (Yes/No) Only available for CA customers. Insurer WCB PEI policy number Only available for CA customers. Patient has Insurer WCB YT (Yes/No) Only available for CA customers. Insurer WCB YT policy number Only available for CA customers. Patient has Insurer IFHP (Yes/No) Only available for CA customers. Insurer IFHP policy number Only available for CA customers. Patient has Insurer FNHA (Yes/No) Only available for CA customers. Insurer FNHA policy number Only available for CA customers. Patient has Insurer ODSP (Yes/No) Only available for CA customers. Insurer ODSP policy number Only available for CA customers. Patient has Insurer DND (Yes/No) Only available for CA customers. Insurer DND policy number Only available for CA customers. Patient insurer(s) Dr. Title Family physician Family physician title Family physician first name Family physician last name Family physician name combined Family physician address (one line) Family physician address (multiple lines) Family physician address (city line) Family physician address (street line) Family physician unit Family physician street number Family physician street Family physician city Family physician province Family physician postal code Family physician billing number Family physician phone number Family physician phone number ext Family physician fax number Last appt date Last appt time Last appt type Last appt location Last appt provider Last assessment date Left HA model name Left HA purchase date Left HA Warranty exp. date Left HA L&D Warranty exp. date Left HA serial number Left HA battery size Left HA notes Left HA service plan name Left HA service plan expiration date Right HA model name Right HA purchase date Right HA Warranty exp. date Right HA L&D Warranty exp. date Right HA serial number Right HA battery size Right HA notes Right HA service plan name Right HA service plan expiration date Other HA model name Other HA purchase date Other HA Warranty exp. date Other HA L&D Warranty exp. date Other HA serial number Other HA battery size Other HA notes Other HA service plan name Other HA service plan expiration date First ALD/Accessory name Accessories must be present in patient’s ALDs/Accessories tab. First ALD/Accessory serial number Accessories must be present in patient’s ALDs/Accessories tab. First ALD/Accessory notes Accessories must be present in patient’s ALDs/Accessories tab. First ALD/Accessory purchase date Accessories must be present in patient’s ALDs/Accessories tab. First ALD/Accessory Warranty exp. date Accessories must be present in patient’s ALDs/Accessories tab. Second ALD/Accessory name Accessories must be present in patient’s ALDs/Accessories tab. Second ALD/Accessory serial number Accessories must be present in patient’s ALDs/Accessories tab. Second ALD/Accessory notes Accessories must be present in patient’s ALDs/Accessories tab. Second ALD/Accessory purchase date Accessories must be present in patient’s ALDs/Accessories tab. Second ALD/Accessory Warranty exp. date Accessories must be present in patient’s ALDs/Accessories tab. Audiogram related fields Audiogram date Latest audiologic data used. MCL Binaural Latest audiologic data used. MCL Left Latest audiologic data used. MCL Right Latest audiologic data used. SRT Binaural Latest audiologic data used. SRT Left Latest audiologic data used. SRT Masked Left Latest audiologic data used. SRT Right Latest audiologic data used. SRT Masked Right Latest audiologic data used. UCL Binaural Latest audiologic data used. UCL Left Latest audiologic data used. UCL Right Latest audiologic data used. WRN Binaural Level Latest audiologic data used. WRN Binaural Noise Latest audiologic data used. WRN Binaural Percent Latest audiologic data used. WRN Left Level Latest audiologic data used. WRN Left Noise Latest audiologic data used. WRN Left Percent Latest audiologic data used. WRN Right Level Latest audiologic data used. WRN Right Noise Latest audiologic data used. WRN Right Percent Latest audiologic data used. WR Binaural Level Latest audiologic data used. WR Binaural Percent Latest audiologic data used. WR Left Level Latest audiologic data used. WR Masked Left Latest audiologic data used. WR Left Percent Latest audiologic data used. WR Right Level Latest audiologic data used. WR Masked Right Latest audiologic data used. WR Right Percent Latest audiologic data used. Left Hearing loss severity Latest audiologic data used. Right Hearing loss severity Latest audiologic data used. Left Hearing loss type Latest audiologic data used. Right Hearing loss type Latest audiologic data used. Left Hearing loss shape Latest audiologic data used. Right Hearing loss shape Latest audiologic data used. Test method Latest audiologic data used. ICD code(s) Latest audiologic data used. Patient type(s) AC Left 125 Latest audiologic data used. AC Left 250 Latest audiologic data used. AC Left 500 Latest audiologic data used. AC Left 750 Latest audiologic data used. AC Left 1000 Latest audiologic data used. AC Left 1500 Latest audiologic data used. AC Left 2000 Latest audiologic data used. AC Left 3000 Latest audiologic data used. AC Left 4000 Latest audiologic data used. AC Left 6000 Latest audiologic data used. AC Left 8000 Latest audiologic data used. AC Right 125 Latest audiologic data used. AC Right 250 Latest audiologic data used. AC Right 500 Latest audiologic data used. AC Right 750 Latest audiologic data used. AC Right 1000 Latest audiologic data used. AC Right 1500 Latest audiologic data used. AC Right 2000 Latest audiologic data used. AC Right 3000 Latest audiologic data used. AC Right 4000 Latest audiologic data used. AC Right 6000 Latest audiologic data used. AC Right 8000 Latest audiologic data used. BC Left 125 Latest audiologic data used. BC Left 250 Latest audiologic data used. BC Left 500 Latest audiologic data used. BC Left 750 Latest audiologic data used. BC Left 1000 Latest audiologic data used. BC Left 1500 Latest audiologic data used. BC Left 2000 Latest audiologic data used. BC Left 3000 Latest audiologic data used. BC Left 4000 Latest audiologic data used. BC Left 6000 Latest audiologic data used. BC Left 8000 Latest audiologic data used. BC Right 125 Latest audiologic data used. BC Right 250 Latest audiologic data used. BC Right 500 Latest audiologic data used. BC Right 750 Latest audiologic data used. BC Right 1000 Latest audiologic data used. BC Right 1500 Latest audiologic data used. BC Right 2000 Latest audiologic data used. BC Right 3000 Latest audiologic data used. BC Right 4000 Latest audiologic data used. BC Right 6000 Latest audiologic data used. BC Right 8000 Latest audiologic data used. MCL Left 125 Latest audiologic data used. MCL Left 250 Latest audiologic data used. MCL Left 500 Latest audiologic data used. MCL Left 750 Latest audiologic data used. MCL Left 1000 Latest audiologic data used. MCL Left 1500 Latest audiologic data used. MCL Left 2000 Latest audiologic data used. MCL Left 3000 Latest audiologic data used. MCL Left 4000 Latest audiologic data used. MCL Left 6000 Latest audiologic data used. MCL Left 8000 Latest audiologic data used. MCL Right 125 Latest audiologic data used. MCL Right 250 Latest audiologic data used. MCL Right 500 Latest audiologic data used. MCL Right 750 Latest audiologic data used. MCL Right 1000 Latest audiologic data used. MCL Right 1500 Latest audiologic data used. MCL Right 2000 Latest audiologic data used. MCL Right 3000 Latest audiologic data used. MCL Right 4000 Latest audiologic data used. MCL Right 6000 Latest audiologic data used. MCL Right 8000 Latest audiologic data used. UCL Left 125 Latest audiologic data used. UCL Left 250 Latest audiologic data used. UCL Left 500 Latest audiologic data used. UCL Left 750 Latest audiologic data used. UCL Left 1000 Latest audiologic data used. UCL Left 1500 Latest audiologic data used. UCL Left 2000 Latest audiologic data used. UCL Left 3000 Latest audiologic data used. UCL Left 4000 Latest audiologic data used. UCL Left 6000 Latest audiologic data used. UCL Left 8000 Latest audiologic data used. UCL Right 125 Latest audiologic data used. UCL Right 250 Latest audiologic data used. UCL Right 500 Latest audiologic data used. UCL Right 750 Latest audiologic data used. UCL Right 1000 Latest audiologic data used. UCL Right 1500 Latest audiologic data used. UCL Right 2000 Latest audiologic data used. UCL Right 3000 Latest audiologic data used. UCL Right 4000 Latest audiologic data used. UCL Right 6000 Latest audiologic data used. UCL Right 8000 Latest audiologic data used. SF Left 125 Latest audiologic data used. SF Left 250 Latest audiologic data used. SF Left 500 Latest audiologic data used. SF Left 750 Latest audiologic data used. SF Left 1000 Latest audiologic data used. SF Left 1500 Latest audiologic data used. SF Left 2000 Latest audiologic data used. SF Left 3000 Latest audiologic data used. SF Left 4000 Latest audiologic data used. SF Left 6000 Latest audiologic data used. SF Left 8000 Latest audiologic data used. SF Right 125 Latest audiologic data used. SF Right 250 Latest audiologic data used. SF Right 500 Latest audiologic data used. SF Right 750 Latest audiologic data used. SF Right 1000 Latest audiologic data used. SF Right 1500 Latest audiologic data used. SF Right 2000 Latest audiologic data used. SF Right 3000 Latest audiologic data used. SF Right 4000 Latest audiologic data used. SF Right 6000 Latest audiologic data used. SF Right 8000 Latest audiologic data used. SFA Left 125 Latest audiologic data used. SFA Left 250 Latest audiologic data used. SFA Left 500 Latest audiologic data used. SFA Left 750 Latest audiologic data used. SFA Left 1000 Latest audiologic data used. SFA Left 1500 Latest audiologic data used. SFA Left 2000 Latest audiologic data used. SFA Left 3000 Latest audiologic data used. SFA Left 4000 Latest audiologic data used. SFA Left 6000 Latest audiologic data used. SFA Left 8000 Latest audiologic data used. SFA Right 125 Latest audiologic data used. SFA Right 250 Latest audiologic data used. SFA Right 500 Latest audiologic data used. SFA Right 750 Latest audiologic data used. SFA Right 1000 Latest audiologic data used. SFA Right 1500 Latest audiologic data used. SFA Right 2000 Latest audiologic data used. SFA Right 3000 Latest audiologic data used. SFA Right 4000 Latest audiologic data used. SFA Right 6000 Latest audiologic data used. SFA Right 8000 Latest audiologic data used. AC Masking Left 125 Latest audiologic data used. AC Masking Left 250 Latest audiologic data used. AC Masking Left 500 Latest audiologic data used. AC Masking Left 750 Latest audiologic data used. AC Masking Left 1000 Latest audiologic data used. AC Masking Left 1500 Latest audiologic data used. AC Masking Left 2000 Latest audiologic data used. AC Masking Left 3000 Latest audiologic data used. AC Masking Left 4000 Latest audiologic data used. AC Masking Left 6000 Latest audiologic data used. AC Masking Left 8000 Latest audiologic data used. AC Masking Right 125 Latest audiologic data used. AC Masking Right 250 Latest audiologic data used. AC Masking Right 500 Latest audiologic data used. AC Masking Right 750 Latest audiologic data used. AC Masking Right 1000 Latest audiologic data used. AC Masking Right 1500 Latest audiologic data used. AC Masking Right 2000 Latest audiologic data used. AC Masking Right 3000 Latest audiologic data used. AC Masking Right 4000 Latest audiologic data used. AC Masking Right 6000 Latest audiologic data used. AC Masking Right 8000 Latest audiologic data used. BC Masking Left 125 Latest audiologic data used. BC Masking Left 250 Latest audiologic data used. BC Masking Left 500 Latest audiologic data used. BC Masking Left 750 Latest audiologic data used. BC Masking Left 1000 Latest audiologic data used. BC Masking Left 1500 Latest audiologic data used. BC Masking Left 2000 Latest audiologic data used. BC Masking Left 3000 Latest audiologic data used. BC Masking Left 4000 Latest audiologic data used. BC Masking Left 6000 Latest audiologic data used. BC Masking Left 8000 Latest audiologic data used. BC Masking Right 125 Latest audiologic data used. BC Masking Right 250 Latest audiologic data used. BC Masking Right 500 Latest audiologic data used. BC Masking Right 750 Latest audiologic data used. BC Masking Right 1000 Latest audiologic data used. BC Masking Right 1500 Latest audiologic data used. BC Masking Right 2000 Latest audiologic data used. BC Masking Right 3000 Latest audiologic data used. BC Masking Right 4000 Latest audiologic data used. BC Masking Right 6000 Latest audiologic data used. BC Masking Right 8000 Latest audiologic data used. MCL Masking Binaural 125 Latest audiologic data used. MCL Masking Binaural 250 Latest audiologic data used. MCL Masking Binaural 500 Latest audiologic data used. MCL Masking Binaural 750 Latest audiologic data used. MCL Masking Binaural 1000 Latest audiologic data used. MCL Masking Binaural 1500 Latest audiologic data used. MCL Masking Binaural 2000 Latest audiologic data used. MCL Masking Binaural 3000 Latest audiologic data used. MCL Masking Binaural 4000 Latest audiologic data used. MCL Masking Binaural 6000 Latest audiologic data used. MCL Masking Binaural 8000 Latest audiologic data used.
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