Hearing/Ear Exam Form

Patient Information

Medical History

Has your child ever been diagnosed with, or experienced any of the following conditions? Check Y, N, or ?

  • Y N Unsure
  • Y N Unsure

Please check child or family to indicate medical history:

  • Child Family
  • Child Family

Insurance Information

Those with Insurance will receive a FULL exam.
Those without Insurance will receive a Screening.
Those that do not pass the Screening are provided a full exam.
Your insurance WILL be billed. You will NOT be billed for the balance. We participate wiuth all insurance companies.


I request and authorize Quality Care for Kids to perform an eye and vision test on my child. I authorize my Commercial, Medicaid or other Insurance Benefits, be paid directly to Quality Care for Kids. I authorize QCFK to provide a summary of findings to my child’s school, physician or specialist if a problem is identified. I’m also signing below to acknowledge that I have received QCFK’s privacy notice that was attached to the front of this consent.