Hearing Services Program Transfer – Electronic Consent

Your details

Fields marked with a red star are the ones we need to start your transfer.

Title

First name Please enter your first name

Last name Please enter your last name

Date of birth

Day

Month

Year

Please enter a valid date of birth

Street address Please enter your street address

Town or suburb Please enter your town or suburb

Postcode Please enter a 4-digit postcode

Mobile phone Please enter a contact number

Home phone

Email address Used to send you a copy of this consent Please check the email address, it does not look quite right

Your card

So we can check your eligibility on the government portal before you arrive.

Which card do you hold?

Pensioner Concession Card DVA Gold Card DVA White Card Not sure

Please choose your card, or "Not sure"

Card number If you have it handy. If not, bring your card when you visit.

Your current provider

Who you are transferring from, so we can make sure your file comes across.

Clinic or company name If you are not sure of the exact name, tell us what you remember and we will find it Please tell us who your current provider is

Where is that clinic? The town or suburb is enough

Power of attorney or guardianship

If someone holds power of attorney, guardianship or a similar arrangement for you, the consent must come from them.

Is a power of attorney, guardianship or similar arrangement in place?

No Yes

Please answer this question

Consent to start your transfer

Please read this, then sign at the bottom.

I have read and agree to the above This lets AIM Hearing begin your transfer in the Hearing Services Program portal. Please tick to give your consent, we cannot start your transfer without it

Your signature

Type your full name below. If you are the power of attorney or guardian, type your own name, not the client’s.

Type your full name Please type your full name to sign

Signed on —

I confirm this is my electronic signature I am the person named above, and I intend this typed name to have the same effect as my handwritten signature. Please confirm your electronic signature

Email me a copy of this consent for my records Recommended. Untick if you would rather not receive one.

Send my copy to Please enter an email address, or untick the box above

Sent securely to reception@aimhearing.com.au. Nothing is stored on this page.

Thank you, we can start your transfer

We will begin your transfer in the Hearing Services Program portal and call you to book your first appointment.

At that appointment you will sign the official government transfer form. We will have it ready for you at the desk.

Start your Hearing Services Program transfer

A few things still need answering