Tested Not Sold Form Patient Name(Required) Date of Visit(Required) Degree of Hearing Loss(Required) Reasons For Not Purchasing. Check All That Apply:(Required) Financial Needs to check with spouse or children Does not perceive the problem is bad enough to get hearing aids Wants to shop around Wants to check insurance Wants to check their Health Savings Account Other If other, please explain:Has the patient scheduled a follow up appointment?(Required) Yes No Please provide any additional information that you think will help the person making the follow-up call:(Required)Name of Submitter(Required) Email of Submitter(Required)
