Registry

Name of patient (Initials only)*

Father's/Mother's Name (Initials only)*

Date of Birth*

Sex*

Resident of (City)*

Resident of (State)*

Pre/Post/Perilingual*

Type of Hearing loss*

Right Ear: Severity of Hearing Loss*

Left Ear: Severity of Hearing Loss*

Cause*

Date of Surgery (dd/mm/yyyy)*

Age at Surgery (in years)*

Side Operated*

Technique*

Entry into Cochlea by*

Implant Company*

Implant Model*

Implant Number*

Date of Switch On

Audiologist

Audiology Center

Operating Surgeon*

Hospital*

Rehabilitationist

Rehabilitation Center

Funding*

I hereby declare that all information provided in the form is accurate, complete, and up-to-date to the best of my knowledge. I also give my consent for this data to be used by CIGI for educational and policy making purposes.

Welcome to Cochlear Implant Registry

THE COCHLEAR IMPLANT GROUP OF INDIA