Campbell County Memorial Hospital
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Ear, Nose & Throat: Forms

Please complete and print the forms below, and bring with you on your visit.

Adult Intake Form

Child Intake Form

The Release of Information Form (in the Adult/Child Intake Forms) must be completed in its entirety before any medical records can be released. The patient's signature and a copy of their photo ID is also required, along with a witness signature. (It can be anybody over the age of 18).

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Website Survey

In 2016, Campbell County Health (CCH) is redesigning its website, www.cchwyo.org, to help the organization provide the best quality care to our patients and residents. To begin this effort, we are asking the public to answer a six-question survey on what items they would like to have on our website. The survey should take no more than five minutes to complete and will closed at noon on Friday, January 29.