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01800 - 963 - 987
407 East 70th Street, 5th Floor
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+1-212-564-EENT (3368)
407 East 70th Street, 5th Floor
Home
About Us
About Dr. Prasad
About Matilda Wissner, Au.D., CCC-A
Our Services
Ears
Nose
Throat
Hearing
Hearing Aids
Patient Instructions
Patient Testimonials
Contact Us
Contact Us
Request an Appointment
Home
About Us
About Dr. Prasad
About Matilda Wissner, Au.D., CCC-A
Our Services
Ears
Nose
Throat
Hearing
Hearing Aids
Patient Instructions
Patient Testimonials
Contact Us
Contact Us
Request an Appointment
EENT Hearing Aid Repair Form – Online Form
Back
Please fill up the following form
Form Date
Patient’s Name
Date of Birth
Patient ID / Account #
Phone
Manufacturer
Model
Serial Number(s)
Date Sent Out
Return By Date (Requested)
Sent To (Manufacturer / Repair Facility)
Tracking / Shipment #
Loaner Provided?
Yes
No
Reason for Repair
No sound / dead unit
Feedback / whistling
Physical or moisture damage
Battery door / contacts damaged
Intermittent sound / static
Program / reset issue
Other
Additional Notes / Description of Issue
Estimated Repair Cost: $
In Warranty?
Yes
No
Authorized to Exceed Estimate Up To: $
FOR OFFICE USE ONLY
Date Received Back
Repair Completed?
Yes
No
Final Cost: $
Patient Notified Date
Returned Via
Picked Up in Office
Mailed to Patient
Send
