GENERIC SIGNIA | Best Value Hearing

Signia Styletto

Signia Order Form
Styletto or Charge&Go

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Step 1: Ship to Information

Step 2: Patient Information

Ship to Account:

Account Name

Phone:

First Name:

Last Name

Age

Insurance plan and ID #

Select your model

Select your Model

Styletto

Charge&Go

Select an option

Tier 7 ($4700.00/pair)

Tier 5 ($4100.00/pair)

Tier 3 ($3500.00/pair)

Tier 1 ($3000.00/pair)

Contact Name:

Email

Bill to Account:

Select a date

Fitting Date:

Purchase Order #:

Model

L

R

Signia Styletto 1X Rechargeable

Fitting Level

Length of Receiver

S

L

R

M

L

R

P

L

R

1

L

R

2

L

R

3

L

R

4

L

R

Color

5 Black Black Gloss

8 Snow White White Gloss

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