Client Mediation Inquiry Form

In submitting this form, I consent to the dispenser/company/manufacturer (“service provider”) making available any of my records that BSHAA may require for the purpose of dealing with my complaint and to BSHAA sending a copy of this form and any documents that I submit to the service provider.

*Denotes a required field

Name*

Date of Birth*

Address Line 1*

Address Line 2*

Town / City*

County*

Postcode*

Please provide some information about the reason you are requesting mediation.*

Name and Contact Information*

I consent to BSHAA collecting, storing and sharing my name and contact information as provided above

Name of Audiologist you dealt with.*

Name of company you dealt with.*

Mediation Information*

I consent to BSHAA collecting, storing and sharing information I provided regarding the issue(s) to be mediated

Additional Information*

I consent to BSHAA collecting, storing and sharing any additional information I provide during the mediation process