Intake Form

Birth Date (required) *
Please ensure your birthdate follows this format: Year-Month-Day

—Please choose an option— Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

• Recent noise exposure? : YesNo

• Ear infection/pain/drainage?: YesNo

• Ear surgery?: YesNo

• Overall health/chronic illness?: YesNo

• Have you ever had your hearing tested? : YesNo

How did you hear about us?
WebsiteGoogle searchSocial mediaJyoti/outreachSign/posterDoctorFamily, friends, or word of mouthOther

Testimonial Consent: By checking this box, I grant permission to Surrey Hearing Care to use my feedback and/or review for marketing purposes, including posting on the clinic's website, social media platforms, and other promotional materials. I understand that my first name and last initial may be used unless I request to remain anonymous.