Patient Forms

If you are insured please have your insurance card handy when scheduling an appointment. Call (310) 559-4884 for questions or to schedule an appointment.

If you are uninsured please let the receptionist know, we are willing to take special considerations and accommodate for your specific financial situation.

New Patient Form

Patients who have never been to one of our offices or have not seen us within the past 3 years, please click below for the New Patient Form. 

New Patient Form

Existing patient Form

Existing patients please click below to submit your questions or appointment requests.

Existing Patient Form

Tinnitus & Hyperacusis Forms

For those patients interested in tinnitus or hyperacusis treatment/therapy options please refer to our Tinnitus & Hyperacusis page and see below for forms. 

Tinnitus Handicap Inventory (THI)

Tinnitus Functional Index (TFI)

Hyperacusis Questionnaire

Dizziness & Vertigo

For those patients experiencing symptoms of vertigo, unsteadiness, dizziness, and other balance disorders, your doctor may want to refer you for a videonystagmography (VNG) balance evaluation. Please see below for forms.

Dizziness HANDICAP INVENTORY (DHI)