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

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* 4. Your contact telephone number:

Different hearing aid batteries available

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* 5. Type of battery

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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.