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* 1. Name

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* 2. How do you rate your hearing?

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* 3. How do you rate your spouse's hearing?

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* 4. Do you believe in Audiology and hearing technology?

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* 5. If you answered no, why not? (if n/a, skip this question)

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* 6. Tell us where you want/need to hear the most. (Select some or all)

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* 7. Tell us about your health plan. You may have a hearing benefit!

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* 8. What value do you place on hearing aids should you need them? 

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* 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!

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* 10. Please rate our CHARITY SERVICE!

If you have questions, email gbailey@songsforsound.com.

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