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

Octicon RUBY 2 Rechargeable MiniRITE

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Signia Styletto 1X

Starkey Livio 1000 rechargeable

Available in ITC, HS or ITE

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BEST

Value Hearing

Signia Styletto

Signia Order Form
Styletto or Charge&Go

Step 1: Ship to Information

Step 2: Patient Information

Octicon RUBY 2 Rechargeable MiniRITE

Signia Styletto 1X

Starkey Livio 1000 rechargeable

Available in ITC, HS or ITE

Quick Links

Insurance Plans

Contact Info

BEST

Value Hearing

Signia Styletto

Signia Order Form Styletto or Charge&Go

Step 1: Ship to Information

Step 2: Patient Information

Octicon RUBY 2 Rechargeable MiniRITE

Signia Styletto 1X

Starkey Livio 1000 rechargeable

Available in ITC, HS or ITE

Quick Links

Insurance Plans

Contact Info

Signia Order Form
Styletto or Charge&Go