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Make an Appointment form
 

 

If you suspect that you have a hearing loss, then you are probably right and it is time to do something about it.

 

Call us today on 1300 557 745 or use the form below and we will be in contact with you to arrange an appointment at a time and location that is most convenient for you.

 

* Denotes required field

Your details

Location:
Click here to choose a location
Title*:
First Name*:
Family Name*:
Street Address*
Suburb/Town*:
State*:
Postcode*:
Date of Birth*:
Email*:
Home phone*:
Mobile phone:
How would you prefer that we contact you?*:
Mobile phone
Email
Home Phone
Please select a day, or days, that are most convenient:
Monday
Tuesday
Wednesday
Thursday
Friday
Please select a time of the day would be convenient to contact you :
9am - 11 am
11am - 2 pm
2pm - 5pm
After hours
Have you had your hearing tested in the last 2-years?
Yes
No
Do you suspect, or has it been confirmed, that you have hearing loss
Yes
No
What best describes your current work situation?:
Working full time
Working part time
Pensioner (inc. part pensioner)
Carer (Home and/or family)
Self-funded retiree
Unemployed
Unable to work (disability)
Student
Other
Please note any other information that you feel is relevant (e.g. possible workers compensation claim):
 
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