INVOICE FORM
Recipient Information
Always complete this section
Recipient's Name
Recipient's DOB
PO #
*
Approval Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
BILLING INFORMATION
Make Check Payable to:
Clinic Name
Street Address
City
State / Province
Postal / Zip Code
INITIAL FITTING
Complete only at initial fitting
Unilateral Fitting, $400
Bilateral Fitting, $600
Device(s) Fit
FOLLOW UP
Complete only at Annual Follow Ups
Follow-Up Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Unilateral Follow-Up, $250
Bilateral Follow-Up, $350
Datalogging hours per day, right device
Datalogging hours per day, left device
Please check everything completed during the appointment.
Comprehensive audiogram
Aided speech perception testing
Earmold impression(s)/fitting
Hearing aid real-ear verification and
Signature
Always complete this section
*
I certify that this child is at least 3 years old and has not yet graduated from high school.
*
I’ve included a copy of the audiogram from the follow-up
This is a first fitting and no audiogram is required
Audiologist Name
*
Audiogram Upload
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Audiologist's Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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