Call for an Appointment
804-288-3277

 

 

Patient Forms

New Patient forms
please complete before appointment

Patient Registration
Medical History
Dizziness Questionnaire
Financial Policy

Misc. Patient forms

Medical Records Release
The Balance and Ear Center follows the state regulations of maintaining a patient medical record for 6 years from their last visit. If the patient was a child when seen by this practice, we will retain their medical records until the child reaches 18 years old and has not been seen within the past 6 years.

Notice of Privacy Practices
Insurance Waiver

Post-Operative Instructions

Ear Tube Placement
Tonsillectomy/Adenoidectomy
Tonsillectomy Diet Instructions
Chronic Ear, Middle Ear or
Stapes Surgery

Neurotologic Patients
Labyrinthectomy and Endolymphatic 
Sac Surgeries

Cochlear Implants
Nasal Surgery

 











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