Application for a Sound Processor (aka BAHA device)

Patient/Child Information

Name *

First

Middle

Last

Date of Birth *

Which ear needs a sound processor? *

Do you require a soft headband? *

Yes
No

Do you currently have a sound processor? *

Yes
No

Please add a couple of paragraphs about your child so we can better understand their specific needs:

Parent/Guardian Information

Parent/Guardian #1

Name *

First

Middle

Last

Address *

City *

Phone *

Secondary Phone

Email *

Secondary Email

Does the Patien/Child live with you? *

Yes
No

Parent/Guardian #2

Name *

First

Middle

Last

Address *

City *

Phone *

Secondary Phone

Email *

Secondary Email

Does the Patien/Child live with you? *

Yes
No

Financial Information

What is your estimated yearly gross household income (before all taxes and deductions)? *

Number of people living in the household as stated on your Federal Tax Return *

We may require a copy of your Federal Tax Return for verification.

Have you sought assistance and been approved by other public or private sources? *

Yes
No

School Information

School Name *

Address *

City *

Phone *

Secondary Phone

School Contacts (Please add Teachers, Administrators, Specialists, etc.): *

Provide Name, Title, and Phone Number

Do we have your permission to contact the school? *

Yes
No

Healthcare/Insurance Information

Do you currently have Health Insurance? *

Yes
No

Has the Patient/Child had an Audiogram within the last 2 years? *

Yes
No

Does the Patient/Child currently have an Audiologist and/or Otolaryngologist? *

Yes
No

By submitting this application, I/We acknowledge that an 2 Ears 2 Learn representative will contact me via phone and/or email to discuss the application and I/We give my/our consent to such contact even if we are on the National Do-Not-Call List. I/We also acknowledge that additional supporting documentation (tax returns, consent forms, etc.) may be required in order for 2 Ears 2 Learn to fully process this application. I/We also acknowledge that 2 Ears 2 Learn does not guarantee this application will be accepted, and I/We agree to accept the determination of 2 Ears 2 Learn as final and without further action.