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New Patient Paperwork

Hearing Aid Preferences

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This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submissions.

* Required Fields

Characteristics of Amplification Tool (COAT)

This form is transmitted securely — your responses are encrypted into a password-protected file for our staff and are never stored on our servers.

This pre-fitting questionnaire helps us understand your communication needs, motivation, priorities, and style preferences before recommending hearing aids.

Top 3 situations where you'd most like to hear better
Ratings (1 = not at all, 5 = very much)
Rank in order of importance (1 = most important, 4 = least important, X = not important)
Would you prefer hearing aids that...
Which styles would you NOT be willing to use? (select all that apply)
BTE (Behind The Ear) hearing aid example
Full Shell hearing aid example
Canal hearing aid example
Mini BTE hearing aid example
Half Shell hearing aid example
CIC (Completely In Canal) hearing aid example

Questions about hearing aids? Call or text our Contra Costa team.

Request a Callback

Whether it's a hearing evaluation, hearing aids, or a question about your hearing, share a few details and our team will call you back.

By submitting, you authorize Contra Costa Hearing Aid Center to text/call the number above for promotional messages, possibly using automated means. Msg/data rates apply, msg frequency varies. Consent is not a condition of purchase. See terms and privacy policy. Text HELP for help and STOP to unsubscribe.