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Do not fill this form out if you're a solicitor.
Who are you looking for hearing aids for?*
- For Myself
- For My Parents
- For My Child
- For My Grandparents
- Other
Does the person in question already have a hearing aid?*
- Yes
- No
Did the doctor recommend hearing aids?*
- Yes
- No
Has a hearing test been conducted by a doctor?*
- Yes
- No

How soon should the hearing loss be improved?*
- As soon as possible
- Within the next few weeks
- Within the next few months
- I don't know
How important is a discreet design?*
- Unimportant
- Important
- Very Important

Which hearing situations are difficult?*
- One-on-one conversations
- Group conversations
- Restaurants/Bar
- Conference
- Church/Concerts
How much does the hearing loss restrict the daily life?*
- Not at all
- Barely
- Severely
Does the affected person have tinnitus?
- Yes
- No
- Not sure

What has prevented you from getting hearing aids sooner?*
- Not sure if I need them
- I can't afford them
- I need more information
- I've been too busy
To evaluate your best possible affordability plan, please tell us in which income group you belong (income per month).*
- Less than INR 20,000
- INR 20,000 - 50,000
- INR 50,001 - INR 1000,000
- More than INR 100,001

How old is the person in question?*
Name*
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