Items or Services
Each hearing aid delivered to the purchaser is identified below as New or Used/Reconditioned.
Above is an itemized breakdown of the total hearing
aid purchase price. If the purchaser timely
cancels the purchase and returns the hearing aid(s) as required by law, Eastside ENT may retain only
the amount permitted under applicable New York law. The balance is due in full at the dispensing
appointment when the purchaser receives the device(s).
The manufacturer may provide a one
time loss and damage replacement benefit for each hearing aid
during the applicable warranty period. The purchaser will be responsible for a $400 replacement
deductible/processing charge per hearing aid, or the manufacturer's then current charge if different and
disclosed before the replacement is ordered. This benefit is governed by the manufacturer's warranty
terms.
*I understand that manufacturer or expedited shipping charges are not included unless specifically
itemized above and may be charged separately after disclosure to me.
I have been advised that during the Eastside ENT in
house service coverage period listed above, routine
in house cleaning and programming visits will be provided without an additional professional service
fee. Manufacturer repairs, replacement parts, receivers, earmolds, accessories, shipping, physical or
moisture damage, loss, theft, and misuse are governed by the applicable manufacturer warranty and may
involve separate charges. After the Eastside ENT service coverage period expires, in house cleaning,
programming, and other services will be subject to the then applicable fees. My clinician has answered
my questions regarding the fitting, use, care, and rehabilitation associated with my hearing aid(s).
I understand that using a hearing aid will not prevent the further loss of hearing nor will it restore normal
hearing. As a result of the information given to me, I understand the nature, degree, and implications of
my hearing loss. I have been trained in the care and use of my amplification device(s) including battery
changing and use of the hearing aid controls.
I understand that I must keep batteries and hearing aids out of the reach of children and animals. If a
battery is swallowed or inserted into the body, immediately call the National Battery Ingestion Hotline at
800 498 8666 and seek emergency medical care.
The purchaser has been verbally advised at the outset of his or her relationship with the registered
hearing aid dispenser that any examination or representation made by a hearing aid dispenser in
connection with the business of dispensing this hearing aid, or hearing aids, is not an examination,
diagnosis, or prescription by a person licensed to practice medicine in this state, and therefore, must not
be regarded as medical opinion.
*A hearing aid that is not returned because it has been lost, stolen, or destroyed does not qualify for
cancellation under the 45 day return provision. Any available loss and damage replacement benefit is
governed by the manufacturer's warranty. This provision does not waive any rights that cannot lawfully
be waived.
If the purchaser cancels the hearing aid purchase within the statutory 45
calendar day trial
period and returns the hearing aid in the condition required by law, Eastside ENT may
retain a cancellation fee not exceeding 10% of the total purchase price of the returned
hearing aid, inclusive of all fees related to dispensing that hearing aid. Any refund will be
calculated in accordance with applicable New York law.
The 45
calendar day cancellation period will be extended by the number of days during
which Eastside ENT, the manufacturer, or their agent has possession or control of the
hearing aid for adjustment, repair, replacement, or servicing.
IN ADDITION TO OTHER RIGHTS, THE BUYER HAS THE RIGHT TO
CANCEL THIS PURCHASE FOR ANY REASON AT ANY TIME PRIOR TO
TWELVE MIDNIGHT OF THE 45TH CALENDAR DAY AFTER RECEIPT OF
THE HEARING AID AND RETURN THE HEARING AID IN THE SAME
CONDITION, ORDINARY WEAR AND TEAR EXCLUDED. BY LAW, THE
SELLER IS ALLOWED TO RETAIN AN AMOUNT UP TO TEN PERCENT OF
THE TOTAL PURCHASE PRICE OF THE CANCELLED HEARING AID,
INCLUDING BATTERIES AND CORDS OR ACCESSORIES THERETO,
INCLUSIVE OF ALL FEES RELATED TO THE HEARING AID.
45th Calendar Day Cancellation Deadline (subject to extension for any period during which
the hearing aid is held for adjustment, repair, replacement, or servicing):
Purchaser's Signature
Registered Audiologist Signature
