SIMPLEX INSTAFITSECURE 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.

Master Card--Visa--Discover

If you are not comfortable revealing your credit card # 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.

Or call us at 1-951-235-4156

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 Audina Simplex Aids would you like?   >>>
Total cost when you buy 2 ($600.00)
Total cost when you buy 1 ($325.00)

(Free priority shipping either way)

Note! If you send this aid back for refund the return fee will be $25. each

Enter Coupon code here >>> Your discount will be deducted automatically when we run your card


To order right ear, left ear or both ears click here -->


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