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Begin Our Hearing Aid Application

Name

Email Address

Phone Number

Mailing Address

Do You Currently Have Health Insurance?

Please describe the nature of your current Health Insurance, if any

Have you been a South Carolina resident for at least one year?

What is your current annual income?

How many persons currently live in your household?

Have you had a hearing test within the last six months? *

*If you answer “no” to this question, please note that you must have a hearing test that is not more than six months old before you can apply.

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