New York City 917 305 7700 • 50 BroadwayFt. Lauderdale 954 601 1930 • 2900 W Cypress Creek Rd

Client information forms

listening-studio-nyt-hearing-aidsWe’re pleased that you have chosen the Center for Hearing and Communication for your hearing healthcare needs. When you come for your appointment, please bring all the information your clinician will need to provide you with the highest quality care.

Intake forms

If you will be receiving audiology services with us for the first time, please download and print our the appropriate intake form. Fill in the requested information and bring the completed form with you when you come for your appointment.

Download the Adult Intake Form

Download the Child Intake Form

Medical Clearance form

If you are required to obtain medical clearance for a hearing aid, please have an ENT fill out the following form and bring it with you when you see your CHC audiologist for a hearing aid evaluation.

Download the Medical Clearance Form

Other important documents

Other information that may be needed:

  • Copies of prior hearing evaluations (if done at another facility)
  • A referral from your doctor if you have Medicare
  • Prior speech and language evaluation results (if available)
  • Psychological evaluation results (if available)
  • IEP or Individualized Education Program (if your child has one)
  • Your child’s immunization documents

If you are uncertain about which information to bring, please call (917) 305-7700 and enter “zero” to speak with the receptionist.

Or send us an email »

Thank you!