Regional Hearing Services Ltd

Head Office:
The Hearing Room
111-113 Fore Street
Saltash
Cornwall PL12 6AE

Telephone: 01752 849295
Fax: 01752 844607

Email:
enquiries@
regionalhearingservices.co.uk

First Name		Last Name
Street Address
City		Postcode
Country
Telephone		Fax
Email

Questionnaire

Please let us know something about your requirements by answering these simple questions:

Do you have difficulty hearing when in a group?		Yes	No
Does your family say that you have the T.V. loud?		Yes	No
Do you feel words are not clear?		Yes	No
Do you ask people to repeat?		Yes	No
Have you had a hearing test before?		Yes	No
If the answer to the previous question was 'yes', was it NHS or private?	N/a	NHS	Private
Do you currently have a hearing aid?	No	NHS	Private
Do you wear your hearing aids?		Yes	No
If the answer to the previous question was 'yes', do you wear them most of the time ('Most') or all of the time ('All')	N/a	Most	All
Would you like us to arrange an appointment?	N/a	AM	PM


(Items in bold are required fields.)