Patient Pre-Registration Form

To help us understand you and your hearing ability, please take a few minutes and complete the information below.  The hearing professional will discuss this with you during your appointment. Take your time and be as detailed as you can. 

Press "Start" to continue with scheduling your free consultation

(5 minutes or less time commitment)
Start
 
Please confirm your full name. *

As it appears on your birth certificate or medical records.
 
What is your phone number? *

 
Please provide the top three listening situations where you would like to hear better *


 
How important is it for you to hear better? *

 
How motivated are you to wear and use hearing aids? *

 
How well do you think hearing aids will improve your hearing? *

 
How important is Improved ability to understand speech in noisy situations (e.g., restaurants, parties)?

 
How important is improved ability to hear and understand speech?

 
How important is hearing aid size and the ability of others not to see the hearing aids?

 
How important is the cost of the hearing aids and treatment plans if necessary?

 
Please describe a recent specific situation when you didn't hear as well as you wanted, and also how this affected you and anyone else. *

 
We recommend bringing a close family member or friend with you to your appointment. We are able to integrate the voice of someone with whom you communicate frequently into the testing process for more personalized results. Will someone be able to join you during your visit? *


 
Who will be joining you and what is their relationship to you? *

Thank you.

Based on your responses, we think we can help!  If you have not done so already, please click the blue button below to select an appointment time for your and your companion to meet with Dr. Powis. We look forward to meeting you soon.

You can also call us directly at 617-773-0900.

- The Quincy Hearing Team
Select Appointment Time
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