EZ HEAR SECURE ORDER FORM

Please fill out each line in the spaces below. You will be submitting this information directly to our order department. This is the fastest way to order Hearing Aids. All orders will ship Monday through Friday within 48 hours from the time we receive it. You may chose the method of shipping below. 

Master Card--Visa--Discover
This site is secure but if you want, we can call you back to get your Credit Card Number. 
You will still need to fill out the rest of the form and submit it to us to order.

Name/           First                            Last

Ship To Address  
Street and number  

City, State, Zip

Telephone (with area code)

E-mail

Name of person on Credit Card

Credit Card #  (Master card or Visa)
    
If you would like a call back for your Card Number, Click on check box 
Expiration Date   Security Code on back of card (Last 3 Digits)

How many E-Z HEAR In Canal Aids would you like?  >>>
Total cost when you buy 2 ($398.00)
Total cost when you buy 1 ($229.00)
Shipping Options -
21 Day return policy.  The fee to return this aid is $11.45 each and will be deducted from your credit.

I have been advised by Heareasy Hearing Aids that the Food and Drug Administration (FDA) has determined that my best interest would be served if I had a medical evaluation by a licensed physician (preferably a physician who specializes in diseases of the ear) before purchasing a hearing aid. (See FDA info on home page)  
I am 18 years of age or older and I do not wish to have a medical examination before purchasing a hearing aid from Heareasy Hearing Aids.

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