Intake Form

Intake Form Book Appointment

Have a Question? 416-364-2264 Online Hearing Test

About Us
Hearing Loss
Products
Accessories
FAQ
Events
Contact Us
- Find Us
- Connect With Us
Shop
- Cochlear Online Store
- MED-EL Online Store

To submit your intake form, simply complete the fields below.

Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
Name*
First Middle Last
Parents Name

(if under 18 years old)
Address*
Street Address Address Line 2 City Province Postal Code
Home Phone*
Cell Phone
Work Phone
Email*
Enter Email Confirm Email
Health Card Number*
Do you have any known respiratory issues?*
- Yes
- No
If yes, please indicate:*
Are you immunocompromised?*
- Yes
- No
Is telecare of interest to you?*
- Yes
- No
If yes what type of device would you use (e.g tablet, mobile)*
Are you currently receiving any of the following services? Please check if applicable:
- ACSD (Assistance for Children with Severe Disabilities))
- ODSP (Ontario Disability Support Program)
- WSIB (Workplace Safety and Insurance Board)
- OW (Ontario Works)
- Blue Cross (DVA)
Insurance Information
Insurance Company
Insurance Phone Number
Personal Insurance Number
Consent
I give consent to UHAC to mail my doctor my results.
Doctors Name
Clinic Name
Interested in our clinics newsletter? We'd love to keep you updated on our clinic and the newest tech!
I consent to receiving the promotional materials:
- by email
- by mail
- both
How did you hear about us? We'd love to say, "Thank you!"
Doctor or Medical Professional
Hospital
Friend/Family/Other
Or chose one if applicable
- Internet Search
- Facebook
- Lyric Advertisement
- Yellow Pages
Signature*

Book Your Hearing Test Today

Name(Required)

Phone(Required)

Email(Required)

Call to book your hearing appointment today

416-364-2264 Book Hearing Test

Hours of Operation

Mon. 8:30 AM – 5:00 PM
Tues. 8:30 AM – 5:00 PM
Wed. 8:30 AM – 5:00 PM
Thurs. 8:30 AM – 5:00 PM
Fri. 8:30 AM – 3:00 PM
Sat. By appointment only
Sun. CLOSED