Customer Number: (if available)  
Bill-To
 Ship-To ( same as bill-to)
Phone  
Email  
HEARING AID INFORMATION
LEFT EAR RIGHT EAR
Style: Full Shell Half Shell Canal CIC
Mini-Canal BTE Body Aid Other		 Style: Full Shell Half Shell Canal CIC
Mini-Canal BTE Body Aid Other
Make Make
Model Model
Serial # Serial #
Base Repair with 6 mo. Warranty (must choose one)
 Base Repair with 6 mo. Warranty (must choose one)
*If you do not know the type or choose the incorrect one, Lloyds will automatically amend your order to reflect the correct price. You will be responsible for the correct balance determined by Lloyds.
ADDITIONAL TO ABOVE (check all that apply)
L R 12-warranty add +$25
L R Loaner add +$25
L R CIC & Body Aids add +$25
L R Custom Aid - shell or faceplate damage add +$80
L R BTE - cracked or broken case add +$60
L R Aids 7 years or older, comes with 3 mo. warranty add +$25
SELECT ONE SHIPPING OPTION BELOW
US Basic (3-5 business days) add +$9.95
US 2 Day (2 business days) add +$13
US Overnight (not available in all areas) add +$20
Int'l Basic (not trackable, Lloyds not liable for non-delivery, S&H adjusted based on pkg weight) Ask For Quote
Int'l Express (trackable, S&H adjusted based on pkg weight) Ask For Quote
REASON FOR REPAIR (check all that apply)
L R Dead L R Battery Drain L R Cracked or Broken Shell / Case
L R Weak/not up to spec L R Intermittent/Fades L R Volume Control
L R Distorted/Noisy/Static L R Wax Build-Up L R Switch / Push-Button
L R Other:
 
PAYMENT INFORMATION
I wish to pay by: Check Money Order Credit Card  (Visa, Mastercard, Discover, or American Express)
IL Residents ONLY: add 1% sales tax
Total Amount Enclosed:

$________.____
Make checks/money orders payable to:

Lloyd Hearing Aid Corp.
4435 Manchester Dr.
Rockford, IL 61109

**Remit payment in US dollars** 		Credit Card #: ___________________________

Expiration Date (mm/yyyy):  ____/_________

Signature: ______________________________
We suggest that you send your repair in a sturdy box and ship by an insurable, traceable means such as FedEx Ground, UPS Ground, or USPS Priority Mail. If you have any questions, please contact us at 1-800-323-4212.

Please allow 2 weeks for standard repair processing time. Thank you.