Pre-Qualification

1. Other than ear infections, is your child healthy?

Yes No

2. Does your child have any of the following?

3 or more episodes ear infections treated with antibiotics in past 6 months.
4 or more episodes ear infections treated with antibiotics in past 12 months.
Persistent fluid in the middle of either ear for more than three months?

Yes No

4. Has your child ever had ear tubes before?

Yes No

Contact Information

Parent Name

Email

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