Patient Forms

Please print and complete all three forms and sign where indicated. Please bring these forms to your appointment. Also, please make sure to bring your Insurance cards to the visit and any Insurance referrals (if required).

For Medicare Patients:
Medicare requires a prescription for a hearing test (with a diagnosis code or reason for testing) in your chart on the date of your test. The prescription must be signed by a Medicare Participating Provider (Primary Care Physician, Specialist or Nurse Practioner). You can bring the prescription with you to your appointment or ask your Physician to fax it or email it to us. 

Please call us with any questions.  Thank you!

Fax: (212) 628-3580
Email: [email protected]