| Print and Fill Out Form | |||||||||||
| Name: | |||||||||||
| Phone # | Date | ||||||||||
| Brand of hearing aid | |||||||||||
| Circle | Left or Right or Both | ||||||||||
| Address: | |||||||||||
| What's wrong with the hearing aid? | |||||||||||
| Dead | Weak | Other (briefly explain) | |||||||||
| Static | Distorted | ||||||||||
| Hearing Aid Repair Services | |||||||||||
| 6 month warranty $105 each | |||||||||||
| 1 year warranty $39.95 extra each | |||||||||||
| 24 hrs Rush Orders $15 | |||||||||||
| Moisture Guard (hearing aid dryer) $89 | |||||||||||
| 40 batteries size 13 312 10 675 $26 | |||||||||||
| Shipping Methods | |||||||||||
| First Class Priority 2-3 days Next Day Mail | |||||||||||
| Free $11.00 $25.00 | |||||||||||
| Payment with Order | |||||||||||
| Credit Card | Check Money Order | ||||||||||
| Visa or Master Card No delay on check orders | |||||||||||
| Fill in the information below for Credit Card Orders | |||||||||||
| Credit Card # | |||||||||||
| Exprartion Date: | |||||||||||
| Security Code # | |||||||||||
| (Last three digits on the back next to your signature) | |||||||||||
| Street address for billing of credit card if not the same as above. | |||||||||||
| E.R. Hearing Aid Repair | |||||||||||
| 102 E. Olive St | |||||||||||
| Lansing, KS 66043 | |||||||||||
| 1-800-976-0601 | |||||||||||
| www.erhearingaidrepair.com | |||||||||||
| Click here to go back | |||||||||||
| You can cut out the address and tape it to the package. | |||||||||||
| Shipping to Canada add $5 dollars for stander shipping and $30 for Priority Mail | |||||||||||