Ear Suspenders Order Form Order NumberThis online order form is for registered audiology customers with an existing account number. If you would like to set up an account, please give us a call or contact us here. For a PDF version of the Microsonic earmold order form, CLICK HERE. Account Number* Step 1: Patient, Audiologist, and Impression DetailsDateBusiness Name*Coupon CodePO# (If applicable)Medicaid# (If applicable)Audiologist Name* Au.D.Ph.D.M.A.M.S.Dr.Mr.Mrs.Ms. Prefix First Last Audiologist Email* Audiologist Phone (USA)Audiologist Phone (International)Special Instructions Step 2: Ear SuspendersEar Suspenders Hearing Aid Headband with adjustable head sizing, silicone grip and sliding silicone sleeves. Ear Suspenders work for all types of hearing loss and devices, whether you or your child wears hearing aids or cochlear implants.Special PricingMicrosonic's Au.D. pricing for Ear Suspenders is $14.00Hearing Aid SizeHearing Aid Size*> Standard> Power 675Age GroupAge Group*> Under 2> Child> Teen / AdultColorPlease select a color for Under 2 size*If you are ordering more than one headband, you may select more than one color. Turquoise Purple Neon Pink Navy Blue Black Brown Beige Neon Green Red Neon Pink Yellow Please select a color for Child size*If you are ordering more than one headband, you may select more than one color. Turquoise Purple Neon Pink Navy Blue Black Brown Beige Orange Red Neon Pink Yellow Please select a color for Teen / Adult size*If you are ordering more than one headband, you may select more than one color. Black Brown Grey Quantity & Special Instructions Step 3: Shipping DetailsShip to Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Select Shipping Method Ground 2nd Day Air Next Day Air USPS Regular USPS Priority Mail Use Your Own Account (optional) FedEx UPS Your Account NumberSpecial Mailing Instructions This iframe contains the logic required to handle Ajax powered Gravity Forms. Visit our Microsonic Store for all your AuD supplies.
