1-888-412-3337
CS@HearingHaven.com
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Shipping and contact Information:

First Name:
Middle Name:
Last Name:
Birth Date: (format = xx/xx/xxxx)
Gender: malefemale
Address:
City:
State:
Country:
Zip/Postal:
Home Phone:
Cell Phone:
Email:
Contact Me By:
How did you hear about us?

Description of the problems with each hearing aid:

Problems:

Programming requests:

If your hearing aids are programmable, please specify any changes you would like made to the hearing aid programming. If none, leave blank.

Any programming done at the time of repair is free. For programming without repair, charges are $50 for one aid, or $75 for two.

Qty. Options (Your audiogram may be required):

Repair Service Options:

Qty.  
In Warranty Repair ($0.00)
Repair ($175 per aid with 1 year warranty included)
Re-case ($275 per aid including repair and 1 year warranty) (?)
48 Hour Turnaround Service ($27.50 - not available on re-cases)
Hearing aid dryer kit ($15)

Return Shipping Method:

Batteries:

Batteries are $39 per carton of 40 batteries.

Battery Size:     How many cartons?

Payment Method:

A check or money order is enclosed
pay online (there is also a link to pay online after submitting this form)
Pay after aid is repaired (we will call you after it is repaired)

Ship Your Hearing Aid(s) To:

Hearing Haven
3740 N. Josey Lane
Suite #125
Carrollton, TX 75007

************IMPORTANT************

Put your hearing aid into a hard container such as a prescription pill bottle, vitamin bottle, or a hard box.
You can place that into a box or padded envelope, but please don't mail your hearing aid in only a padded envelope.
Your hearing instrument will be protected much better this way.
Solution Graphics