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CONTACT US

Abenity STARKEY

Step 1: Ship to Information

Step 2: Patient Information

Ship to Account:

Account Name

Phone:

Contact Name:

Email

Select a date

Fitting Date:

Purchase Order #:

Select Style

L

R

CIC Non Rechargeable (10)

L

R

ITC Non Rechargeable (312)

L

R

Half Shell Rechargeable

L

R

Full Shell Rechargeable

L

R

Evolv Ai RIC Rechargeable

Select the Tier

2400 ($4700.00/pair)

2000 ($4100.00/pair)

1600 ($3500.00/pair)

1000 ($3000.00/pair)

First Name:

Last Name

Age

Insurance plan and ID #

Audiometric Information

(required)

Hz:

R

250

500

1K

2K

3K

4K

6K

L

250

500

1K

2K

3K

4K

6K

Faceplate Color

Options

Pink

Light Brown

Medium Brown

Chestnut

Dark Brown

Black

RIC color options

Champagne

Silver

Dark Brown

Black

L

Push Button

Rotary Wheel

Rotary + Button

No Controls

Directional Microphones

Induction Coil

Hear Clear

Extended Tube

Removal Handle

Removal Notch

R

Push Button

Rotary Wheel

Rotary + Button

No Controls

Directional Microphones

Induction Coil

Hear Clear

Extended Tube

Removal Handle

Removal Notch

Fitting Level

Receiver Gain

Receiver length (for RIC models only)

L

50

60

70

R

50

60

70

L

1

2

3

4

5

R

1

2

3

4

5

I agree to the terms & conditionsView terms of use

I confirm that I have asked my patient or patient representative for permission to submit this order form.

Enter the amount for payment. Order will not be placed with manufacturer until paid in full

$

Each new hearing aid comes with a 3-year warranty that covers loss, damage and repair. Loss and damage warranty may require a $300 deductible out of pocket for replacement or if damaged beyond repair. All repair/replacement will be done at the fitting clinic and charges will be paid directly at the clinic. Please call (435) 239-8860 with any questions. For additional questions please email orders@insurancehearingaids.org

Together with

Contact us

info@bestvaluehearing.org

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