Forms

INSTRUCTIONS FOR USING HUSHMAIL

You will be given a choice to log in to Hushmail (our secure messaging system) using Google, Microsoft, or Apple. Check your spam if you do not receive the email as expected.  If you have previously logged in to Hushmail using a passphrase, you must continue to use the same passphrase moving forward.

Instructions for using Patient Portal

UNCG Speech and Hearing Center will send an invitation to your email address. The invitation is valid for 8 hours only. You will create an account by entering the patient’s date of birth and setting a secure password. The portal will include all of the forms (new client and appointment specific) that you need to complete with directions about how to complete them. Guardians also may create a separate portal that will allow them to see their dependent’s information. However, the forms must be completed in the patient’s portal.

NEW CLIENT FORMS

Forms are available through the online patient portal or may be completed by downloading the pdf documents below. After completion, forms can be either printed and mailed or emailed securely to scheduling@csdshc.uncg.edu.

ALL CLIENTS SHOULD COMPLETE THE FOLLOWING:

• Client Information Form(PDF)  – download, complete, and sign
• Notice of Privacy Practices (PDF) – please read
• Client Intake Form (PDF) – download, complete, and sign
• Authorization for Disclosure of Protected Health Information (PDF) – download, complete, and sign
• Telepractice Consent (PDF) – please read
• Email Consent (PDF) – please read
• Communication Permissions (PDF) – download, complete, and sign

AUDIOLOGY FORMS

PATIENTS TO BE SEEN FOR EVALUATION OF HEARING OR AUDITORY PROCESSING SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History (PDF)
• Child Audiology Case History (PDF) – Birth to 17 years

PATIENTS TO BE SEEN FOR TINNITUS SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History (PDF) or Child Audiology Case History (PDF)  – Birth to 17 years
• Secure Online Tinnitus Form

PATIENTS TO BE SEEN FOR SOUND SENSITIVITY (HYPERACUSIS) SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History (PDF) or Child Audiology Case History (PDF)  – Birth to 17 years
• Secure Online Hyperacusis Form

PATIENTS TO BE SEEN FOR MISOPHONIA SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History (PDF) or Child Audiology Case History (PDF) – Birth to 17 years
• Secure Online Misophonia Form

SPEECH AND LANGUAGE CLIENT FORMS

(Complete as appropriate)

• Adult Speech-Language Case History (PDF) 
• Child Speech-Language Case History (PDF)  – Birth to 17 years
• Adult Accent or Dialect Modification Case History (PDF)