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