Referrer Contact Number:
Student Contact Telephone:
Duration of studies remaining (including any part years):
Information required for quotation
Items requested for quotation – e.g. Roger System or any other suitable assistive listening device or radio aid (ALD)
Does the user have a hearing instrument?
Yes - Single
Yes - Left and Right
Please provide full make and model of hearing aid (normally printed on the reverse or battery door).
Please provide the FULL DETAIL or we may not be able to quote.
Hearing aid colour (manufacturer colour code if known):
Is the student aware of which specific programmes are active on the hearing aid? (Not required for quote)
If yes to the above, please list below
Optionally please upload an image of the hearing aid for identification purposes
Allowed extensions .jpg, .png, .gif. Maximum size 5MB.