GENERIC OTICON | Best Value Hearing

Oticon Rechargeable MiniRITE

Oticon Order Form

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Step 1: Ship to Information

Step 2: Patient Information

Ship to Account:

Account Name

Phone:

Contact Name:

Email

Bill to Account:

Select a date

Fitting Date:

Purchase Order #:

Fitting Level

Length of Receiver

60 Gain

L

R

85 Gain

L

R

100 Gain

L

R

1

L

R

2

L

R

3

L

R

4

L

R

First Name:

Last Name

Age

Insurance plan and ID #

Select your model

Oticon Real 1R $4700.00/pair

Oticon Real 2R $4100.00/pair

Oticon Real 3R $3500.00/pair

Oticon Zircon 2R $3000.00/pair

Color

Dome Type and Size

Open Dome

L

R

Power Dome

L

R

Bass Dome

L

R

L

Size 5

Size 6

Size 8

Size 10

R

Size 5

Size 6

Size 8

Size 10

5

L

R

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