Please print this Form and have you Doctor sign it and date it.

If this is your first time buying a hearing aid, Heareasy Hearing Aids suggests that you first get an examination by a medical Doctor (preferably an ear specialist) to specifically check you for any of the following conditions.
1.Visible congenital or traumatic deformity of the ear. 
2.History of active drainage from the ear within the previous 90 days. 
3.History of sudden or rapidly progressive hearing loss within the previous 90 days. 
4.Acute or chronic dizziness. 
5.Unilateral hearing loss of sudden or recent onset within the previous 90 days. 
6.Audiometric air-bone gap equal to or greater than 15 decibels at 500(Hz), 1000(Hz), and 2000(Hz). 
7.Visible evidence of ear wax (cerumen) or any foreign body in the ear canal. 
8.Pain or discomfort in the ear.

Name of Patient ______________________________________________________

Age of Patient   ______________________________________________________

Date this form was signed by the Doctor  __________________________

Doctors Name  _______________________________________________________

Doctors Address  ___________________________________________________

_______________________________________________________________________

I have examined the Patient listed above and have cleared HE/She
FOR THE PURPOSE OF PURCHASING HEARING AIDS.

DOCTORS SIGNATURE  __________________________________________

Doctors State License # ______________________________________

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