How to Get and Complete the Costco Hearing Aid Patient Intake Form

The Costco hearing aid patient intake form is officially called the Confidential Member Case History Form. You download it as a PDF from the Costco Hearing Aid Center page at costco.com, print it, fill it out by hand, and bring the completed paper copy to your appointment.¹ There is no digital submission option and no portal for uploading past audiograms or medical records. If you don’t have a printer at home, arrive at the warehouse early enough to complete the form on paper before your appointment starts.

Where to Get the Form

Go to the Costco Hearing Aid Center page on costco.com and use the link to print the intake form.¹ Use black ink and write legibly. A staff member has to transcribe your answers into Costco’s electronic records at check-in, so anything they can’t read slows the appointment down. On checklist sections, mark “no” or add a clear check rather than skipping lines. Blank lines read as missed questions, not as answers.

What the Form Asks and How to Answer It

The form runs several pages across five sections. Knowing what each one wants before you start writing produces better answers, and better answers translate directly into better hearing aid recommendations if you end up needing them.

Member Information

Standard identification: name, date of birth, address, phone numbers, email, Costco membership number, warehouse name and number, spouse or partner’s name, and whether you’re working or retired.² Keep your membership card next to you while you fill this out. The warehouse number is printed on it.

Medical History

You’ll check off current medications from a list that includes blood thinners, heart medications, insulin, chemotherapy drugs, and pain relievers. You’ll also flag allergies to latex, silicone, rubber, and plastics, since hearing aids and custom ear molds sit against your skin for hours at a time.²

A longer checklist covers conditions that can affect hearing or fitting: diabetes, high blood pressure, Meniere’s disease, stroke, meningitis, neuropathy, vision problems, memory issues, depression or anxiety, and others. You’ll note any ear surgery or medical treatment for your ears and the age it happened.² If you’re not sure about a condition, write “unsure” rather than leaving it blank so the specialist knows you saw the question.

Hearing History

Spend the most time here. The form asks whether you’ve had a hearing test before, when and where, and whether hearing loss was detected. It asks about tinnitus in detail: which ear, what the sound is like, how often it happens, and whether it bothers you. You’ll describe noise exposure history (years in a loud workplace, regular firearm use, concerts without ear protection) and any family history of hearing loss.²

If you currently wear hearing aids or have worn them before, a subsection asks about the type, how long you’ve used them, which ears, how often you actually wear them, what you like and dislike about them, and whether you’ve ever returned a pair. Be honest about the dislikes. That information shapes what the specialist recommends.²

Hearing Needs Assessment

You’ll rate your overall hearing on a 1-to-10 scale and list the three situations where you most want to hear better. Think about these before you write. “Restaurants” and “TV” are the answers everyone gives. Specifics do more work: hearing a grandchild at the dinner table, following movie dialogue without turning the volume to 40, following a meeting when several people talk at once.²

You’ll also rank priorities among size and visibility, speech understanding, performance in noisy environments, and cost, and note whether you prefer automatic adjustments or manual controls and whether you want to stream audio from a phone, tablet, TV, or computer.² If you have a phone preference, write down whether it’s an iPhone or an Android. Bluetooth compatibility varies by hearing aid brand.

Medical Considerations and Privacy Initials

The final page lists conditions that may require a physician’s evaluation before a fitting: active ear drainage within the past 90 days, sudden or rapidly worsening hearing loss within the past 90 days, chronic dizziness, ear pain, and visible abnormalities of the ear or ear canal.² Checking one of these boxes doesn’t disqualify you from the hearing test. The specialist discusses whether you need medical clearance before proceeding to a fitting.

The form ends with a privacy notice and an information statement. Each needs your initials to acknowledge how your health data is stored and used within the Costco system.²

Membership Requirement

A paid Costco membership is required to use the Hearing Aid Center, and hearing tests are available to members 18 or older.¹ If you’re filling out the form to help a parent or another family member, they either need their own membership or need to come with you as a guest. Call the local center ahead of time to confirm how they handle it, because individual warehouses sometimes interpret the policy differently.

What to Bring to the Appointment

Schedule the appointment by calling your nearest Costco Hearing Aid Center directly. Location-specific numbers are on the warehouse locator at costco.com.¹ Bring three things:

The completed, printed intake form.
Your Costco membership card. Staff verify membership at the warehouse entrance and again at the Hearing Aid Center counter.
Your current hearing aids, if you wear them, even if they are old or broken. The specialist will want to see the model and may check how they’re performing.

If you have a recent audiogram from another provider, bring it as well. The form doesn’t ask for one and there’s no way to upload it, but a paper copy gives the specialist a comparison point.

1
Costco. Hearing Aid Center
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Costco. Hearing Aid Center Confidential Member Case History Form