Patient Forms

Patient Intake Form

This form captures basic demographic data for patients

new to us.

Patient History

This form helps collect patient hearing and medical history.

Characteristics of Amplification Tool

This form helps us to better understand your amplification needs.  

Notice of Privacy Practices

This describes our clinic's privacy practices and informs you of your rights regarding your personal health information.  

Notice of Privacy Practices Receipt

This form acknowledges receipt of our Notice of Privacy Practices.


& Financial Policies

This form explains our Appointment and Financial policies.

1161 St. Charles Street, Suite A

Houma, Louisiana  70360

Phone:  (985) 262-7335
Fax: (985) 302-0887

Hours: M-Th 9am-4pm

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