In order to better serve you, you may be asked to print and complete one or more of the forms below.  The forms must be completed legibly and using black ink.  In order for you to print these forms, you will need Acrobat Reader if you do not have it installed on your computer.

If you have any difficulty finishing the questionnaires or if you have questions about their content, please feel free to contact us so that we may help you.  You will still need to be present at least 15 minutes prior to your appointment so that patient registration may be completed.

Please choose the appropriate form(s):

Patients with

VOICE difficulties

Patients with

SWALLOWING difficulties

Voice Evaluation Case History

Swallowing Function Questionnaire

Voice Handicap Index (VHI)

Please note:

As of January 1, 2003 the Radiology Department will collect co-payments and deductibles from all insured patients who present for radiological procedures.  To remain compliant with managed care contracts, patients who have insurance requiring a co-payment or deductible must pay the amount that their plan specifies at the time of service.  Since they will be doing this for all insured patients, the Department of Radiology will also be collecting a radiology visit deposit from all uninsured patients at the same time.  This fee only applies to patients who are having Modified Barium Swallow Studies or outpatient voice evaluations by Dr. Halstead.