Hearing Professionals- Free HAE Use the form below to request an appointment. One of our patient managers will contact you to schedule an appointment to come in and see us First Name (required)*Last Name (required)*Date-of-Birth (required)* Your Email Primary Phone # (required)*Alternate PhonePreferred Office LocationSidney, OhioTroy, OhioAre you a new patient?YesNoIf yes, have you had your hearing tested within the last year?YesNoDo you currently wear a hearing aid(s)?YesNoPlease describe the reason for your visit? (required?)*Please let us know a preferred appointment date. Again, this does not represent your actual appointment date, we will call you and confirm your appointment date and timeMorningLunchEveningDate Time : HH MM AM PM This iframe contains the logic required to handle Ajax powered Gravity Forms.