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Your Nameyour full name
Phoneyour Phone number
Date of Bookingof appointment
Timeof appointment
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Test Your Hearing

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Your Hearing Score is [ field1 + field5 + field6 + field11 + field15 + field10 + field16 + field14 + field17 + field18 + field20 + field19 ]

If your Hearing score is < 140 – Hearing Loss – Consult nearest centre
Between 140 to 200 – Mild Hearing loss 
Greater than 200 – No Hearing loss

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