Who are you seeking information for? *

Myself

Someone else

If you're filling out this form for someone else, please answer based on their experience.

Do you have hearing loss? *

Yes

Not Sure

Do you experience ringing or buzzing in your ears (tinnitus)? *

Yes

Have you had your hearing tested? *

Yes, within the past six months

Yes, within the past two years

Yes, more than two years ago

Have you used hearing aids? *

I've never used hearing aids

I've used hearing aids before, but don't currently use them

I currently use hearing aids

Please upload the most recent results of your hearing test or audiogram here:

Audiogram File Upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )If you do not have the results readily available, you can skip this step for now and share with the audiology team at a later date.

What are your main hearing challenges? *

Frequently asking people to repeat themselves

Understanding phone calls

Hearing family or friends

Hearing in noisy enviornments

Hearing in meetings or at work

Following conversations in groups

Hearing the TV

Other

How do your hearing challenges impact you? *

Feeling mentally drained or fatigued

Feeling left out or disconnected

Feeling self-conscious or embarrassed

Feeling anxious in conversations

Avoiding social situations

Straining loved ones or relationships

Other

Other than you, who notices your hearing loss the most? *

Friends

Family

Coworkers

None

What motivated you to look for care?

How soon do you plan to take action on your hearing wellness? *

Immediately

Within the next month

In a few months

Just exploring options

What are you expecting to spend on your treatment? *

First Name *

Last Name *

Phone *

Email *

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