Hearing Aid Interest Form

Thank you for working with us. We look forward to helping you with your hearing needs.

Please fill out this form to the best of your abilities so that we can help guide you:

First Name

Last Name

Phone

State

Why would you like to work with us?

How did you hear about us?

Are you tech savvy?

Have you had a recent hearing test?

How long have you had hearing loss?

How would you describe your hearing loss?

Click Here for the Hearing Handicap Assessment Form.

Do you currently wear a hearing aid?

If yes, what brand?

If Yes, How old is your current hearing aid?

What style is it?

Do you wear earmolds with your hearing aids?

Do you utilize assistive listening devices or hearing aid accessories?

Are you interested in a consignment hearing aid to save money?

Do you have a local audioligist that you see that you want to continue working with?

If you don't, do you want us to help find a local provider?

If possible, would you be interested in a remote teleaudiology appointment?

Would you prefer to work with us via:

Are you interested in a specific hearing aid brand?