Patient Forms

1161 Saint Charles St., Suite A, Houma, LA 70360 985-262-7335

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.

Appointment & Financial Policies

This form explains our Appointment and Financial policies.

SHOULD I SEE AN AUDIOLOGIST?

Not hearing as well as you used to? Are you experiencing new or odd symptoms in your ears? Take our quiz to find out if it’s time to come see us.

STAY TUNED