Hearing Aid Program Adjustment

From: $35.49

Please fill out this hearing questionnaire. Your hearing aid program adjustment will be planned around this form, so be thorough! When you are finished with this form, click Add to cart.

* Please answer every question.
If you leave one blank, you can’t finish!

  • Fit and Comfort

    (You cannot hear a lot of background noises, or it feels like you're wearing earplugs, or sounds that aren't amplified by your hearing aid are badly dulled by your earpiece, etc.)

    If you answered yes to this question, and you use an earmold (not a tube tip), you might need to have the earmold modified. Earmold modification is considered a hearing aid repair, and you should think about having us modify that for you!

    Overall Volume

    Volume in Certain Frequency Ranges

    (Deep sounds include bass drums, low voices, rumbling thunder, etc.)

    (High-pitched sounds include childrens voices, tea-kettle whistles, chimes, etc.)

    (Mid-range sounds mostly include adult voices, a lot of music, and most modern electronic devices.)

    Missing Sounds

    (S's, B's or T's, for example, or soft sounds like "Th" in "The")

    (Does it sound like you're in a well, or in a barrel, or in a tunnel?)

    (As if everyone were robots, or computer voices, etc.)

    Extra Sounds

    (Such as buzzing, sharp clipping noises, or "white noise")

    (Loud thumping, as if a bass drum were being played randomly)

    ("Pumping" is when the volume of sound goes up and down rapidly.)

    ("Tinny" sounds like it is coming from a small, cheap speaker, with no low-pitch sound at all.)

    ("Harsh" may include clipping off of the beginning or ends of words, or of hard consonants, usually does not have much low-range sound in it.)

    (Squealing or high-pitched noises that might change when your hand is near your ear)

    Final Thoughts

    • (max file size 64 MB)

    Fax or postal mail option:

  • Return Shipping Options

    • 14.5 $
    • 19.5 $
    • 24.5 $
    • $
SKU: N/A Category:


Your Hearing Aid Program Adjustment will be done according to the form above. We will ship your adjusted hearing aid back to you when it is ready, according to your choice above. International clients must use the FedEx Shipping Calculator to calculate the final return shipping rate. International clients will be contacted for return shipping payments when the adjustment is done.

When sending your hearing aids to HearSource, please put the aids in a crush-proof container. An old plastic pill bottle, or a vitamin bottle works great. Put the bottle into your box or envelope. This will protect the hearing aids from crushing and moisture damage! Please include all of the extra parts (including ear-molds and tubes), so our lab can be thorough!

Additional information

Which Ear(s)?

Left, Right, Both Ears


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