Custom Product Impression Information and Order Form.

This is the form to take with you to your local Audiologist. The second page has information on the type of impressions we are looking for.

If you are buying from or sales staff at our main office, please fill the form out completely and include it with the impressions when you send them

If you are purchasing here online please make sure to fill out the name of the persons the impressions are for and the Audiologists' information. Include the filled out form as well as a copy of the Order Number you received in an Email from the store when you complete the checkout. You do not have to fill in the "Bill To, Ship To or the Items Requested" fields as we will have them already. You have 20 days to get the impressions to us, after which the online purchase will be voided and we have to re-enter the sale manually. This is not a problem, just a delay in service to you.

 Click on the PDF icon to open in a new window or right click on it to save a copy for later use.  ORDER FORM V8.3.1    

If you need to down load the latest Adobe® Reader® click on the followning. 

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