Current Start Payment Complete Number of children to register 123 Location Mount Elizabeth Novena Hospital Appointment Dates Check slots availability 2 slots left 1 slot left fully booked First Child Information Full Legal Name Date of screening - Select -21-July-202430-July-20242-August-20243-August-202413-July-20246-August-202416-July-20248-August-202414-August-202426-July-202418-August-2024 Time of screening - Select -09:00am09:30am10:00am10:30am11:00am11:30am12:00pm12:30pm01:00pm01:30pm02:00pm02:30pm03:00pm03:30pm04:00pm04:30pm Birth Certificate / Passport No Date of birth Has your child been to any hearing screening before? Yes No If “Yes”, please state: Hospital / Polyclinics ENT Clinics / Paediatric Clinics Others Please Specify When was your child’s last hearing screening? Less than 6 months Between 6 -12 months More than 12 months Did your child require care in the Neonatal Intensive Care Unit (NICU) for more than 5 days or have high bilirubin levels at newborn stage requiring hospitalisation? Yes No If “Yes”, please give details: Has your child been diagnosed / suspected of any hearing condition(s)? Yes No If “Yes”, please state: Has your child been diagnosed with ear infection before? Yes No If “Yes”, please state when Do you have any concern about your child’s hearing, speech, language or development? Yes No If “Yes”, please state your concern(s): Is there a family history of any hearing condition(s)? Yes No If “Yes”, please provide details Second Child Information Full Legal Name Date of screening - None -21-July-202430-July-20242-August-20243-August-202413-July-20246-August-202416-July-20248-August-202414-August-202426-July-202418-August-2024 Time of screening - Select -09:00am09:30am10:00am10:30am11:00am11:30am12:00pm12:30pm01:00pm01:30pm02:00pm02:30pm03:00pm03:30pm04:00pm04:30pm Birth Certificate / Passport No Date of birth Has your child been to any hearing screening before? Yes No If “Yes”, please state: Hospital / Polyclinics ENT Clinics / Paediatric Clinics Others Please Specify When was your child’s last hearing screening? Less than 6 months Between 6 -12 months More than 12 months Did your child require care in the Neonatal Intensive Care Unit (NICU) for more than 5 days or have high bilirubin levels at newborn stage requiring hospitalisation? Yes No If “Yes”, please give details: Has your child been diagnosed / suspected of any hearing condition(s)? Yes No If “Yes”, please state: Has your child been diagnosed with ear infection before? Yes No If “Yes”, please state when Do you have any concern about your child’s hearing, speech, language or development? Yes No If “Yes”, please state your concern(s): Is there a family history of any hearing condition(s)? Yes No If “Yes”, please provide details Third Child Information Full Legal Name Date of screening - None -21-July-202430-July-20242-August-20243-August-202413-July-20246-August-202416-July-20248-August-202414-August-202426-July-202418-August-2024 Time of screening - Select -09:00am09:30am10:00am10:30am11:00am11:30am12:00pm12:30pm01:00pm01:30pm02:00pm02:30pm03:00pm03:30pm04:00pm04:30pm Birth Certificate / Passport No Date of birth Has your child been to any hearing screening before? Yes No If “Yes”, please state: Hospital / Polyclinics ENT Clinics / Paediatric Clinics Others Please Specify When was your child’s last hearing screening? Less than 6 months Between 6 -12 months More than 12 months Did your child require care in the Neonatal Intensive Care Unit (NICU) for more than 5 days or have high bilirubin levels at newborn stage requiring hospitalisation? Yes No If “Yes”, please give details: Has your child been diagnosed / suspected of any hearing condition(s)? Yes No If “Yes”, please state: Has your child been diagnosed with ear infection before? Yes No If “Yes”, please state when Do you have any concern about your child’s hearing, speech, language or development? Yes No If “Yes”, please state your concern(s): Is there a family history of any hearing condition(s)? Yes No If “Yes”, please provide details Parent’s/ Guardian’s information Full Legal Name Contact Number Email Address Where did you hear about Earscreen? Referral from Paediatrician Referral from friends/Cordlife client Events/Roadshow Cordlife email Cordlife website Cordlife Facebook/YouTube Cordlife Investor Relations Website Online Forum Other… Enter other… Why did you enrol for Earscreen? Suspect my child has hearing issue(s) Good to know / Try it out Family history of hearing loss Important to check Other… Enter other…
