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Patient Membership Request Form

Full Name

Age

City and Country of Residence

WhatsApp Or Google Meet Contact Number

Occupation

Primary Concern and Current Need

If you have a hearing aid, how long have you been using it?

If you’re dissatisfied with your current hearing aid, please explain why?

To address your hearing concerns, which quality level of hearing aids would you prefer? (Basic, Functional, Premium)

Are you currently using a hearing aid?

Have you recently had a hearing test?

Do you have an Audiogram report? Upload it