Give the Gift of Hearing | ENT Care Center

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address City State Zip Code

Who is your hearing care provider?(Required)

Date of Most Recent Hearing Evaluation

Referring Audiologist(Required)

Have you been diagnosed with hearing loss?(Required)

Yes

No

Do you currently use hearing aids?(Required)

Yes

No

How old are your current hearing aids?(Required)

Do you have insurance coverage for hearing aids?(Required)

Yes

No

What is the amount covered?(Required)

Please briefly explain why you are requesting financial assistance(Required)

What would better hearing mean for you?(Required)

Household Annual Income

Under #20,000

$20,000 – $35,000

$35,000 – $50,000

Over $50,000

Number of people in your household

Including yourself

Please enter a number greater than or equal to 1.

Please share how receiving hearing aids would impact your daily life(Required)

Date(Required)

Signature

Gift of Hearing Assistance Application