Mini Fund Audiology Quote

This mini-application is for financial assistance up to $400 for audiology services for a child up to age 21 in the Northeastern and Northcentral Wisconsin area.

*Ear Molds

*Dehumindifiers or Dryers

*Hearing aid batteries

*Hearing aid lost / repair

*Hearing Exam

This is not an all inclusive list, and is subject to modifications. If your request is for something other than above, please let us know in the application below.

The quote will be reviewed by the board in a timely manner and you will be contacted with a decision.

Hear in the Fox Cities will provide funding for minor expenses as long as the funds are available. We reserve the right to change eligibility at any time without written notification.

BEFORE YOU BEGIN, PLEASE HAVE YOUR QUOTE READY TO UPLOAD
TO BE COMPLETED BY THE AUDIOLOGIST
Patient Name*
Name
Patient Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Audiologist Name*
Audiologist Phone #*
Format: (000) 000-0000.
Patient needs help with
If something else, please write below
paragraph
Please upload the quote

Cancelof
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