User registration form
Given name*: Surname*: Sex*: Born*: E-mail*:
--choose--
prefer not to say
male
female
year
01
02
03
04
05
06
07
08
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month
Leave "not applied" below in case of natural hearing
Correct, natural hearing: Date of implantation: Implant type: Processor name: Hearing aid:
Left ear:
yes
no
Right ear:
yes
no
Comments
1
:
I hereby acknowledge receipt and understanding of the following documents:
Information on the Protection of User Data
,
Regulations Governing Electronic Services
, and
Information Regarding the Utilization of Data Collected on the Platform for Scientific Research
. I confirm acceptance of the
Platform Regulations
and I attest to the contents outlined in the
User Declarations
.
*
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* Required fields, e-mail needed to send password
1
Other additional explanations related hearing that the user would like to provide