Tinnitus New Patient Form

IMPORTANT: If you are experiencing a sudden loss of hearing, drainage from the ears or facial numbness or paralysis, contact the Ear, Nose and Throat Clinic for an appointment immediately at 414-805-5580.

Is Your Primary Concern Hearing Loss? 
If your primary concern is hearing loss, and your tinnitus is not distressing, you do not need to complete the tinnitus packet. We recommend you begin with a comprehensive hearing evaluation. Contact central scheduling to schedule a hearing evaluation at 414-805-5587.

You can expect a call within a week of your form submission.

Patient Agreement

The following form is for the Tinnitus and Hyperacusis Program management/consultation appointment to guide you in how to manage the distress of your symptoms and reduce the impact symptoms have on your life. Our team may recommend this appointment. This is determined once we have received and reviewed your completed form, including the patient agreement below.

If you prefer, you can fill out a paper copy of this form that you can fax or mail to the program.

Please check each of the items below and sign at the bottom. Checking the items and submitting the form indicates that you have read and understand the terms outlined here.

I understand that and agree to the following terms (check each):

IMPORTANT: Insurance does not cover the cost of tinnitus counseling and management. The cost for the service is $180. Follow-up counseling is billed at $120 per visit. Any test procedure, including hearing tests, for tinnitus will be billed to your insurance. It is your responsibility to determine with your insurance company if hearing testing is covered, including deductibles and co-pay. You will be responsible for the cost of services not covered by your health insurance. These fees do not cover the cost of hearing aids, earplugs and/or sound generating devices.

NOTE: The purpose of our program is to help guide patients in managing the distress of their symptoms. If you are involved in any legal action regarding your symptoms, our doctors and clinicians are not available as expert witnesses or to provide any legal guidance.