Hearing Aid Donation Program - Recipient Application
At Innisfil Hearing, we believe everyone deserves the opportunity to hear life’s most meaningful moments. Through our Hearing Aid Donation Program, gently used hearing aids are refurbished, professionally programmed, and provided to individuals in need — free of charge.Please complete the form below so we can get to know you and determine how we can help.
Hearing Aid Recipient
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Are you the recipient?
*
Yes
No, I'm applying for someone else
If you are applying for someone else, tell us who you are and what's your relationship to the applicant. Please include your name, phone number, and email address.
Why are you applying for the Hearing Aid Donation Program?Please, tell us your story and share what inspired you to apply and how improved hearing could make a difference in your daily life or relationships.
*
Does the recipient currently wear hearing aids?
*
Yes
No
Used to
If yes, what make/model are they? (or unknown)
How long ago was the last hearing test
*
Less than 1 year ago
1-3 years ago
3+ years (or unknown)
Please describe the hearing difficulties you are experiencing:
*
Eligibility Information
Our program is intended for community members who would benefit from hearing support but may not have access to new hearing aids.
Are you currently employed?
*
Full-time
Part-time
Retired
Unemployed
Student
Disability
Other
Do you currently have hearing aid coverage through insurance or government assistance (other than OHIP/ADP)?
No insurance
Private insurance
DVA
ODSP
WSIB
Other
Please share a statement on how improved hearing would impact your daily life:
Program Details
Recipients will receive: A comprehensive hearing evaluation, professional fitting and programming of donated hearing aids, two follow-up fine-tuning appointments for adjustment and optimization(Additional visits available on a fee-for-service basis)
Acknowledgement:
I understand that hearing aids provided through this donation program are refurbished devices, provided as-is, and are not eligible for manufacturer warranties. Follow-up care beyond the included visits may be subject to standard service fees.
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