Partner Inquiry Tell us more about your business Contact Name Business Name Mailing Address City Province / State Postal / ZIP Code Email Phone Number What type of businss do you operarte or are affiliated with? Pharmacy Audiologist Hearing-related Dispensery Family Physician Digital Health Provider Optical Retailer Noise-exposed Business What is the square footage of your business? What is the square footage of your business? Do you have a separate room for consulting and coaching your patients? Yes No Do you offer a range of home healthcare products and have a knowledgeable staff member to assist? Yes No Do you sell any hearing instruments now in addition to the products offered on your "hearing shelf"? Yes No Do you service your patients via telemedicine over the internet? Yes No Do you service your patients via telemedicine over the internet? Yes No Are you an independent business or member of a corporate chain? Independent business Corporate chain Other Are you an independent business or member of a corporate chain? Independent business Corporate chain Other Are you an independent business or member of a corporate chain? Independent business Corporate chain Other Do you operate from a single location or several? If more than one, how many? Do you operate from a single location or several? If more than one, how many? Do you operate from a single location or several? If more than one, how many? Do you operate from a single location or several? If more than one, how many? Are hearing aid sales and service an important part of your practice? Yes No Are you actively providing in-person services in your community? Yes No Are you actively providing in-person services in your community? Yes No Are you a practitioner or a group practice? Solo Group Do you currently test patients for their hearing status? Yes No Does your practice offer health related products? Yes No What services do you offer? What languages (in addition to English) do you provide? Have you considered adding hearing health as a related business line? Yes No Are you an individual or business that provides health related services? Individual Business Are you exposed to significant noise in your workplace or during recreational activities? Yes No Do you presently experience hearing problems? Yes No Do you regularly use hearing protection? Yes No Are you presently using hearing aids? Yes No Are you an independent business or member of a corporate chain? Yes No Do you operate from a single location or several? If more than one, how many? What services do you presently offer? If hearing health services are offered, what type are they? Have you considered adding hearing health as a related business line? Yes No Questions & Comments Submit
