Hearing Aid Battery Request Form

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1. Your name:

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2. Your Date of Birth:

Please enter DD/MM/YYYY

Date

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3. Your address (Required.)

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4. Your contact telephone number: (Required.)

Different hearing aid batteries available

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5. Type of battery (Required.)

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6. Do you need any of the following: (select all that apply)

Replacement Tubing for Ear Mould(s)

Replacement Thin Tubes and Domes

Cleaning Rods

Please note that only NHS Shropshire, Telford & Wrekin Audiology patients will be supplied with batteries or tubing using this form.