Songs for Sound Hearing Health Profile - Your Hearing, Your Budget, Your Wishes

Question Title

* 1. Name

First Name

Last Name

Phone number (include area code)

Question Title

* 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.

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* 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.

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

Yes

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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)

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

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* 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 #

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* 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

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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!

Mornings (8 am - 12 pm)

Afternoons (12-4:30 pm)

What day(s) of the week are best? Enter all here

Songs for Sound Hearing Health Profile - Your Hearing, Your Budget, Your Wishes

Question Title

* 1. Name

Question Title

* 2. How do you rate your hearing?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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!

Question Title

* 10. Please rate our CHARITY SERVICE!If you have questions, email gbailey@songsforsound.com.

* 10. Please rate our CHARITY SERVICE!

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