Hearing Aid Priorities Form Please fill out our Hearing Aid Priorities Form prior to your first hearing aid evaluation Name * First Name Last Name Email * Please select UP TO 5 statements that are most important to you when selecting new hearing aids I want to hear the TV at a lower volume I need the lowest cost hearing aids available I don't want anyone to see my hearing aids I want to have my hearing aids adjusted from home without an in-person appointment I want rechargeable hearing aids I want the most-tech savvy devices on the market My hearing aids should reduce noises behind me I would like to hear better in church I want to control my hearing aids through my smartphone I want to understand speech in noise environments I want to hear women and children clearly I want to be able to answer my cell phone calls through my hearing aids I am never in loud noise, and only spend time in quiet environments If I learn that I am a hearing aid candidate, I will be highly motivated to pursue hearing aids. Strongly Disagree Disagree Neutral Agree Strongly Agree My budget for hearing aids is Please select your allotted budget for A PAIR of hearing aids Under $2000 / pair $2000-3500 / pair $3500-5000 / pair Under $6000 / pair Any What kind of cell phone do you have? iPhone Android I do not have a smartphone Do you have a home phone? Yes No Thank you for filling out the Hearing Aid Priorities Form. This will help your audiologist suggest the best hearing devices for you. We will be in touch.
