Medical and Hearing History Form
Request a Callback
Whether you have a question, a concern or would like to speak to me to discuss any challenges that you may be facing, then I am here for you. There is no such thing as a silly question. Simply complete this form and when I’m available between appointments, I’ll call you back for a friendly no-obligation conversation.
Request a Callback
Whether you have a question, a concern or would like to speak to me to discuss any challenges that you may be facing, then I am here for you. There is no such thing as a silly question. Simply complete this form and when I’m available between appointments, I’ll call you back for a friendly no-obligation conversation.
Request a Callback
Whether you have a question, a concern or would like to speak to me to discuss any challenges that you may be facing, then I am here for you. There is no such thing as a silly question. Simply complete this form and when I’m available between appointments, I’ll call you back for a friendly no-obligation conversation.
Patient Resources

It’s an ironic truth Clement knows well: “When you have a hearing loss, you’re probably the last to know—or I should say, accept it.” For years, his wife and children gently but persistently encouraged him to get a hearing test. Clement, however, preferred to deal with the problem by turning up the TV volume and constantly asking people to repeat themselves.
Patient Resources

It’s an ironic truth Clement knows well: “When you have a hearing loss, you’re probably the last to know—or I should say, accept it.” For years, his wife and children gently but persistently encouraged him to get a hearing test. Clement, however, preferred to deal with the problem by turning up the TV volume and constantly asking people to repeat themselves.
Patient Resources

It’s an ironic truth Clement knows well: “When you have a hearing loss, you’re probably the last to know—or I should say, accept it.” For years, his wife and children gently but persistently encouraged him to get a hearing test. Clement, however, preferred to deal with the problem by turning up the TV volume and constantly asking people to repeat themselves.
©2025 Jacobs Audiology | All Rights Reserved
©2025 Jacobs Audiology | All Rights Reserved
©2025 Jacobs Audiology | All Rights Reserved



