I have given consent to an audiologist from Melody Hear For You to take impressions of my ears to make custom ear plugs. I understand that impression taking involves minor risks such as small abrasions or minor bleeding.

I understand that all records are confidential and governed by the Privacy Act.  Provision of results to any other person or agency will require my written consent.

Please complete payment at least 24hours before the appointment by credit card (sub-charge applies) or direct bank transfer as specified on your invoice. If due to unforeseen circumstances we need to cancel your appointment, a full refund will be provided.