Club Application for Hearing Conservation

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This universal form is available to anyone in need of a standard hearing exam and/or basic hearing aids. The forms collected will be forwarded to the Lions Club in the area closest to your residence for acceptance.

Email *

Patient Name *

Date of birth *

YYYY

Parent or guardian name (if minor) or person completing application for patient (if unable)

Mailing Address *

Mailing Address City *

Mailing Address State *

Mailing Address Zip Code *

Physical Address (if different from mailing address)

What Lions Club is nearest to your home?

How long have you resided at this address? *

Home phone/primary phone number *

Cell phone/secondary phone number

If you referred by a medical professional or agency, please let us know who.

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