Member Application

Disclaimer:
By providing Hearing Choice your information we will treat that information in accordance with the Data Protection Act 1988 and related privacy legislation and will aim to meet current Internet best practice. The personal information you give us will never be supplied to anyone outside of Hearing Choice without first obtaining your consent, unless we are obliged or permitted by law to disclose it.

To Fax your application print this link and fill out your application and fax to 831-449-1661: Hearing Choice Fax Application

*First Name:
*Last Name:
*Email:
Address:
City:
State:	Please SelectAlabamaAlaskaAlbertaAmerican SamoaArizonaArkansasArmed Forces (AE)Armed Forces Americas (AA)Armed Forces Pacific (AP)British ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundland and LabradoNorth CarolinaNorth DakotaNorthern Mariana IslandsNorthwest TerritoriesNova ScotiaNunavutOhioOklahomaOntarioOregonPalauPennsylvaniaPrince Edward IslandPuerto RicoQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingYukonOther
Zip:
County:
Phone:
Hearing Loss?:	Yes  No
Have You Had a Hearing Test?:	Yes  No
Current Type of Hearing Loss:	Sensorineural Conductive Mixed Unknown
How long have you had your hearing loss?:	0-3 years 4-7 years 8-10 years 11-15 years 16-20 years 21-30 years
Do you wear hearing aids?:	Yes  No
Current Brand?:	Oticon Siemens Widex Phonak Sonic innovations Starkey Bernafon GN ReSound Lyric Other
Have you owned more than one set of hearing aids?:	Yes  No
Are you happy with your provider?:	Yes  No
Are you looking for a new provider?:	Yes  No
How much did you pay for your current hearing aids?:	$1,000 each $1,000-$2,000 $2,000-$3,000 $3,000-$4,000 >$4,000