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Songs for Sound Hearing Health Profile - Your Hearing, Your Budget, Your Wishes
*
1.
Name
(Required.)
First Name
Last Name
Email
Phone number (include area code)
2.
How do you rate your hearing?
I hear great! I just want an annual hearing test.
I hear well most of the time.
I hear okay.
I don't hear well.
I know I need help now.
I hear great! I just want an annual hearing test.
I hear well most of the time.
I hear okay.
I don't hear well.
I know I need help now.
3.
How do you rate your spouse's hearing?
They hear great! I just want them to get an annual hearing test.
They hear well most of the time.
They hear okay.
They don't hear well.
They need help now.
They hear great! I just want them to get an annual hearing test.
They hear well most of the time.
They hear okay.
They don't hear well.
They need help now.
4.
Do you believe in Audiology and hearing technology?
Yes
No
5.
If you answered no, why not? (if n/a, skip this question)
6.
Tell us where you want/need to hear the most. (Select some or all)
Music/Church/Concert/Radio
Restaurants/Social Events
TV & at home with family
Work/Office/Boardroom/Video Conf Calls
Outdoors/Nature/Playing Sports
School/College/Education
7.
Tell us about your health plan. You may have a hearing benefit!
Cigna
Aetna
United Healthcare
Blue Cross Blue Shield
Anthem
Humana
OTHER
n/a
Group # and Individual #
8.
What value do you place on hearing aids should you need them?
$300-$900
$900-$1500
$1600-$2200
$2300-$3000
$3100-$4000
$4000-$6000
9.
Tell us more about appointment preference! What days/times are best? Be as specific as you want. Our Care Team will call you to confirm!
Mornings (8 am - 12 pm)
Afternoons (12-4:30 pm)
What day(s) of the week are best? Enter all here
10.
Please rate our CHARITY SERVICE!
If you have questions, email gbailey@songsforsound.com.
1 star
2 stars
3 stars
4 stars
5 stars
Current Progress,
0 of 10 answered
