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Medical Specialties

At the Center for Neurosciences, we work together across specialties to provide the best, most comprehensive approach to treatment.

Ear & Hearing Forms

COVID-19 Memorandum to Patients

Dr. Jacob New Patient Letter
Dr. Jacob Cancellation Policy
TMC Surgery Scheduling Order Form
Preoperative Instructions
Preoperative Instructions Spanish
Dr. Jacob Call Coverage
Cochlear Implant Vaccination Information
Cochlear Implant Vaccination Information Spanish

Consent Forms

Ear Surgery General Consent Form
Ear Surgery General Consent Form Spanish
Bone Anchored Hearing Implant Consent Form
Bone Anchored Hearing Implant Consent Form Spanish
Envoy Esteem Consent Form
Envoy Esteem Consent Form Spanish
Facial Nerve Decompression/Nerve Graft Consent Form
Facial Nerve Decompression/Nerve Graft Consent Form Spanish
Gentamicin Injection Consent Form
Gentamicin Injection Consent Form Spanish
Middle Fossa Surgery Consent Form
Middle Fossa Surgery Consent Form Spanish
Myringtomy and Tubes Consent Form
Myringtomy and Tubes Consent Form Spanish
Removal of Facial Cyst Consent Form
Resection of Skull Base Tumors Consent Form
Resection of Skull Base Tumors Consent Form Spanish
Stapedectomy Consent Form
Stapedectomy Consent Form Spanish
Steroid Injection Consent Form

Office Intake Forms

Ear and Hearing Adult New Patient Intake Form
Ear and Hearing Established Patient Intake Form
Ear and Hearing New Pediatric Patient Intake Form

OR Data Forms

BTI Data Sheet
Chronic Ear Data Sheet
Hearing Implant Data Sheet
Neurotology Data Sheet
Stapes and Middle Ear Data Sheet

Post-Operative Instructions

Attract System Bone Anchored Hearing Implant Post-Operative Instructions
Chronic Ear Surgery Post-Operative Instructions
Cochlear Implantation Post-Operative Instructions
Cochlear Implantation Post-Operative Instructions Spanish
Direct Connect Bone Anchored Hearing Implants Post-Operative Instructions
Direct Connect Bone Anchored Hearing Implants Post-Operative Instructions Spanish
Ear Tube Post-Operative Instructions
Endolymphatic Sac Post-Operative Instructions
Endolymphatic Sac Post-Operative Instructions Spanish
Esteem Processor/Battery Change Post-Operative Instructions
Esteem Processor/Battery Change Post-Operative Instructions Spanish
Middle Fossa Surgery Post-Operative Instructions
Middle Fossa Surgery Post-Operative Instructions Spanish
Petrosectomy with Ear Closure Post-Operative Instructions
Petrosectomy with Ear Closure Post-Operative Instructions Spanish
Petrosectomy/Ear Closure/Cochlear Implantation Post-Operative Instructions
Skull Base Surgery Post-Operative Instructions
Stapedectomy Post-Operative Instructions
Surgical Labyrinthectomy Post-Operative Instructions
Tonsillectomy/Adenoidectomy Post-Operative Instructions

Private Pay Surgical Procedures

Envoy Esteem Battery/Processor Change Letter
Envoy Esteem New Implant Letter
Envoy Esteem New Implant Letter Spanish
Ototronix Maxum New Implant Letter
Cochlear Americas BAHA Attract Letter
Cochlear Americas BAHA Connect System Letter
Cochlear Americas BAHA Connect System Letter Spanish

Audiology Protocols

Audiology Welcome Letter
Audiologic Evaluation
Auditory Training Resources for Cochlear Implant Recipients
Bone Anchored Hearing Implant
Chemotherapy (Ototoxicity) Surveillance
Cochlear Implant Candidacy
Cochlear Implant Evaluation Protocol
Hearing Aid
Vestibular Evaluation
Vestibular Testing Preparation