District 29-L Lions Club Application for Hearing Conservation
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 address *
Patient Name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Parent or guardian name (if minor) or person completing application for patient (if unable)
Your answer
Mailing Address *
Your answer
Mailing Address City *
Your answer
Mailing Address State *
Your answer
Mailing Address Zip Code *
Your answer
Physical Address (if different from mailing address)
Your answer
What Lions Club is nearest to your home?
Your answer
How long have you resided at this address? *
Your answer
Home phone/primary phone number *
Your answer
Cell phone/secondary phone number
Your answer
If you referred by a medical professional or agency, please let us know who.
Your answer
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