Free Cochlear Implant Eligibility Assessment

Confidential. No cost. A HearClear counsellor will personally review your information and guide you on the next steps. This is not a diagnosis.

Patient information

Patient type *

Age (years) *

Patient / Parent name *

Mobile number *

Email (optional)

City *

State

Hearing concern

Main concern

Hearing loss duration

Current diagnosis (if any)

Currently using

Is hearing aid helping?

Speech development

Upload audiogram / BERA / ASSR report (PDF / image, optional)

Preferences & consent

Preferred language

Preferred callback time

I consent to HearClear contacting me for cochlear implant guidance and storing my information securely. I understand this assessment is not a diagnosis.