Print and Fill Out Form
	Name:
	Phone #			Date	Date:
	Brand of hearing aid
	Circle	Left   or    Right   or    Both
	Address:
	What's wrong with the hearing aid?
	Dead	Intermittent     Shell
	Door	Weak	Other (briefly explain)
	Static	Distorted
	Hearing Aid Repair Services
	3 month warranty                     $115   each
	6 Month warranty       add       $24     each
	1 year warranty           add       $45     each
	48 hrs Rush Orders   add       $20
	40 Batteries size 13 312 10 675     $27
	New shell or copy aid (clone) or new circuitry call for price.
	Shipping Methods
	First Class                      Priority 2-3 days            Next Day Mail
	Free                                    $13.00                          $22.00
	Payment with Order
	Credit Card		Check              Money Order        Call for payment
	Visa or Master Card        No delay on check orders
	Fill in the information below for Credit Card Orders
	Credit Card #
	Expiration Date:
	Adress for credit card statement if different from address.
	Kansas Hearing Aid Repair
	814 E. Main St #155
	Gardner, KS 66030
			1-800-976-0601
	www.erhearingaidrepair.com
			Click here to go back
	You can cut out the address and tape it to the package.
		Only Kansas residents tax will be add.