Patient Forms

Providing our specialists with specific information before your appointment refreshes our minds concerning your case and allows us to customize your care. We have made that as convenient as possible by making the various forms we use available to download.

New Patient Forms

If you have not seen one of our medical doctors within the past three years, it is necessary for you to complete our “new patient forms.” To save time at your next appointment, download and print the forms. Please fill in the blanks and bring them with you to your next office visit.

New Patient Forms
New Patient Forms
Existing Patient Forms

Existing Patient Forms

If you’re an existing patient and have not seen one of our medical doctors within the past three months, then it is necessary to complete our “existing patient form.” You can download these forms, print them, and fill in the necessary information. Please bring the completed forms with you to your next visit to our offices.

Existing Patient Forms

Physical Therapy Forms

Prior to your visit with Dr. Samantha Stolper, please download the proper physical therapy forms, so Dr. Stolper can customize your care to meet your unique needs. Print the forms, fill in the necessary information, and present them to our receptionist when you arrive for your appointment.

Physical Therapy Forms
Physical Therapy Forms
Allergy Intake Form

Allergy Intake Forms

If the purpose of your visit with us is related to allergies, please download our allergy intake form, print it, provide the necessary information, and bring it with you to your allergy appointment.

Allergy Intake Form

Authorization For Release Of Medical Records

In some instances, we may need you to authorize the disclosure of information from your health records for insurance or other purposes. If prompted for a release of medical records, please download the form, print and complete it, and then bring it with you for your appointment.

Authorization For Release Of Medical Records
Authorization For Release Of Medical Records
Food/Diary Consumption Form

Food/Diary Consumption Form

For various diagnoses, we sometimes ask our patients to record everything you eat and drink, including water. If you have been asked to do this, please download the form, print it, and use it to record the information we need. Where possible, note key ingredients, such as salt/sodium content, especially when you notice a change in your vestibular symptoms soon after your meal. Bring the completed form to your next appointment for analysis.

Food/Diary Consumption Form
You don’t realise you’re walking with a rock in your shoe until you’re able to hear again – Regina’s Story

Regina has suffered from hearing problems since she was an infant, recognized as regular chronic ear infections. And, as with unfortunate events, she has experienced a multitude of audiology catastrophes.

It was many years before Regina crossed paths with Scottsdale Ear, Nose & Throat; where her lifetime of hearing problems was addressed effectively and treated with the delicate care that she desperately required.

Regina’s journey began when she was taken to a regular paediatrician by her mother from a young age. Her ears were, what we describe as an audiologists recipe for disaster, ‘flushed out’.

This dangerous procedure caused a nasty infection, which spread to her mastoid bone and, at the age of 15, she underwent a tympanoplasty mastoidectomy to stop the infection spreading. This only forbade her future struggles with hearing loss. 

As with poor diagnosis, Regina was faced with another canaloplasty which didn’t work. Soon after, she received a BAHA, which is a cochlear implant in her skull that acts as a sound processor that detects sound and transforms it into vibrations. 

However, suffering from a history of poor hearing care, she was unaware of the former issues her ear presented.

By now, this would be described as any audiologists nightmare. But, we’re proud to have helped Regina on her road to optimum hearing and reconnect her to her loved ones.

When she arrived at Scottsdale Ear, Nose & Throat it was evident that she was losing hearing on her right side. At this point, she was fitted with a ReSound hearing device, which provided the catalyst to a new and improved hearing.

The first thing Regina noticed was the indefinite sound she had been making whilst emptying the dishwasher, completely unaware of the noise she was making!

“I mean, the detail that I can hear now it’s like, Whoa, I didn’t realize I was making that much noise. I need to be quieter!”

Treated with professional care, Regina received a comprehensive hearing assessment with Dr. Debra Hamila.

“I just love, love, love Dr. Hamila, she is such a professional and loving person. I was so impressed with the office and what she did with the ReSound, I just love her.”

Like many others, it takes years for people to realize they have a hearing problem. Regina described this moment as life-changing.

“You don’t realise you’re walking with a rock in your shoe until you’re able to hear again. Especially now I’m a full-time Grammy Nanny, I can hear so much more and it has enriched my life incredibly.”

What advice would you give to someone who is deliberating on taking the first step towards better hearing?

“My advice to them would be to have a hearing test. Especially as we age our hearing goes down. It’s really unfortunate that people carry their pride and are not willing to learn to walk with the rock in their shoe. You don’t realise you’re waking with a rock in your shoe until you’re able to hear again.”

Regina is one of many patients who has been impacted by our audiological services and we are proud to have been able to provide the tool towards better hearing and a lifetime of many more memories.