Audiology Center of Burbank — home
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New patient forms

Patient registration

Your contact details, physicians, insurance and an emergency contact.

  • About 5 minutes
  • Sent securely to our office; not saved on this website
  • Every new patient

Online sending isn’t switched on yet

You can look through the forms, but they can’t be sent from this website yet. Please complete them at your visit, or call (818) 859-7730.

  1. About the patient
  2. Doctors & insurance
  3. Emergency contact
  4. Authorization & signature
  5. Review & send

About the patient

Names as they appear on the patient’s insurance card. Please give at least one phone number.

Format: two-digit month, day, then four-digit year.

Required for patients under 18.

Doctors & insurance

Please bring your insurance cards to your visit so our staff can copy them. We’ll ask for the policy holder’s Social Security number at the office, not online.

If different from the referring physician.

Send the report to

If different from the patient.

Format: two-digit month, day, then four-digit year.

Emergency contact

Authorization & signature

I authorize the release of information necessary to determine liability for payment and to obtain reimbursement on my claim. I request that payment of authorized benefits be made on my behalf. I assign benefits payable to which I am entitled to Burbank Audiology Center. I understand that I am responsible for any copayments at the time of the visit.

Who is filling out this form? (required)

I agree to sign this form electronically. Typing my name below is my signature, with the same effect as signing the paper form.

Draw your signature (optional)

Use your finger, a stylus or a mouse. If you skip this, your typed name is used as your signature.

Review & send

Please check your answers. Use “Edit” to change anything before you send.

Reconnect with
what matters.

Request an Appointment(818) 859-7730