Registration Form

First Name:

Last Name:

Serial Number Right:

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Gender:

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Purchase Date
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Where Purchased :

Waiver of Medical Evaluation Requirements
I have been advised by EarCon Technologies, Inc. that the Food and Drug Administration has determined that my best health interest would be served if I had a medical evaluation by a licensed physician, preferably a physician who specializes in diseases of the ear, before purchasing a hearing instrument. I am 18 years or older, and voluntarily sign this waiver which indicates that I do not wish a medical evaluation or test before purchasing a hearing instrument. (This is an FDA regulated product. Please be sure to complete your product registration and sign the waiver found on the Registration Card).

I have had a medical evaluation in the past six months.

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