Enrollment Form
Street
City/ Zip
Telephone
E-mail address
Do you wear hearing aids?
Please tell us about your hearing loss
Please tell us why you wish to become a member
Please answer the following questions and send them to us. You will be notified shortly whether you have been accepted in the the Hearing Aid Services of Hollywood Preferred Patient Program. (Southern California residents only please)
Name:Street
City/ Zip
Telephone
E-mail address
Do you wear hearing aids?
Please tell us about your hearing loss
Please tell us why you wish to become a member
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7083 Hollywood Blvd., Suite 302
Hollywood, CA 90028 Phone (323) 463-7109 Fax (323) 463-7707 E-mail: info@lahearing.com |
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