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? *

 
What is your home street address? *

Please be sure to include apartment or unit number if applicable.
 
City? *

 
State? *

 
What is your Date of Birth? *

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


 
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. *

 
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? *

 
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? *

 
If we could help improve your hearing ability through the use of hearing aid technology, how willing are you to invest financially in being part of a comprehensive treatment plan?

Please rate on a scale from 1-10, 1 being "I have no interest in investing financially in hearing aids", and 10 being "I am very open to investing financially in hearing aids if I know they can help". *


 
Is there anything else you would like the doctor to know about you that is important?

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 617-934-1184.

- The Quincy Hearing Team
Select Appointment Time
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Thank you.

Your patient pre-registration profile has been submitted successfully. 
Due to high demand, Quincy Hearing is currently on a wait list for new patient scheduling.  We will give you a call when Dr. Powis is accepting new patients.

You can also reach us directly at 617-934-1184 to learn more about our services or inquire about appointments.

- The Quincy Hearing Team
Why Dr. Powis is Right For You
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