REQUEST AN APPOINTMENT

Name & Surname:

Email:

Phone:

Patient:
—Please choose an option—AdultChild

Province and Preferred Institute:
—Please choose an option—Gauteng - Queenswood, PretoriaGauteng - Lynnwood, PretoriaGauteng - Rosebank, JHBGauteng - Fourways, JHBGauteng - Bryanston, JHBGauteng - RoodepoortGauteng - BenoniKwaZulu-Natal - Durban NorthKwaZulu Natal - HillcrestKwaZulu Natal - BallitoKwaZulu Natal - PietermaritzburgKwaZulu Natal - Shelly BeachKwaZulu Natal - KokstadMpumalanga - NelspruitMpumalanga - WitbankMpumalanga - MiddelburgNorthern Cape - UpingtonNorth West - PotchefstroomNorth West - RustenburgLimpopo - PolokwaneWestern Cape - BellvilleWestern Cape - ClaremontWestern Cape - Somerset WestWestern Cape - GeorgeWestern Cape - Sea PointEastern Cape - East LondonFree State - BloemfonteinNamibia - WindhoekNamibia - Swakopmund

Do you sometimes miss words in a conversation or on the phone?

YesNo

Do you often ask people to repeat themselves?

YesNo

Does your family complain that the TV is too loud?

YesNo

Do you struggle to follow a conversation in a crowded restaurant?

YesNo

When having conversations, do people often sound like they're mumbling or not speaking clearly?

YesNo