New Patient Forms

Please print, complete and bring the following forms to the clinic upon your initial visit.

Client Information-English

Client Information-Spanish

 

Audiology Case History-English

Audiology Case History-Spanish

 

The Program for the Amplification of the Children of Texas (PACT) is no longer available.

 

***ALL NEW AND EXISTING MEDICAID PATIENTS MUST

1)HAVE A REFERRAL FROM THEIR PCP (PRIMARY CARE PHYSICIAN) or ENT (EAR, NOSE AND THROAT PHYSICIAN)

AND

2) FAX A COMPLETED CHS REFERRAL FORM, WHICH CAN BE DOWNLOADED HERE,

BEFORE SCHEDULING AN APPOINTMENT***

 

If you have further questions please call CHS Audiology Assistant, Sandra Alvarado at (713) 523-3363 ext. 124


 

The Center for Hearing and Speech does not discriminate in admissions or scholarship programs against any individual on the basis of sex, race, color, national or ethnic origin, or religion.