Statement Of Waiver Of Medical Evaluation

Please fill out this quick waiver before purchasing your hearing devices.


I do state:

That I have been advised by MildLossHearingDevice.com, or anyone acting under their authority, that the Food and Drug Administration has determined that my health interest would be best served if I had a medical evaluation by a licensed physician prior to being fit with a hearing device(s).

I am choosing to decline their recommendation for such an evaluation.

I believe in my own judgment that I am qualified as a candidate for a hearing device(s).

I also understand that a copy of this statement will be kept on file by MildLossHearingDevice.com for a period of three years from this date, in accordance with the Food and Drug Administration regulations.

Please enter the required legal information below before ordering your AmplifyEar Hearing Device. Please read the above information waiver. By entering your name below you agree to the terms stated above.

Your Full Name:

Your Email Address:

Your Phone Number:

I have read the above waiver and I agree: Yes
(please check 'Yes' if you agree)

 

 

No hearing devices will be shipped without a properly filled out waiver of Medical Evaluation.

-The Management