May Better Hearing Month Pre Order Form

Contact Information

Patient Name (required)

Contact Name (if different from patient)

Contact Email Address

Contact Phone Number (required)

Your Selections

Week 1 - Hearing Screening and Hearing Aid Coupon
Send me a $500 coupon todayCall me to book a complimentary hearing screening for a family member or friend

Week 2 - Hearing Aid Batteries
Select a Size3121310I don't know*Select Quantity1 box (40 cells)2 boxes (80 cells)3 boxes (120 cells)4 boxes (160 cells)

* If you are unsure of the size we will contact you.

Week 3 - Hearing Aid Accessories
Please note supplies are limited and available on first come first serve basis.

I want to pre-order my FREE:
To select multiple on a desktop press the Ctrl key
Remote controlTV streamerPhone streamer

I would like more information on:
To select multiple on a desktop press the Ctrl key
Remote controlTV streamerPhone streamer

Week 4 - Dri aid Jar and Capsules
Select a Dri-Aid OptionDri aid jar (1)Dri aid capsules (6 pack)

Note:
Dri aid jar is for ALL hearing aids including battery operated hearing aids.
Dri aid capsules are for rechargeable Resound or Starkey aids only.