INVOICE FORM
APPLICANT INFORMATION
Applicant’s Name
DOB
PO #
*
Initial Fitting Date
/
Month
/
Day
Year
Date
BILLING INFORMATION
Audiologist
Make Check Payable to
Billing Office Address
Billing Contact
Email
example@example.com
INITIAL FITTING
Please complete at initial visit
Unilateral Fitting, $400
Bilateral Fitting, $600
Device(s) Fit
FOLLOW UP
Complete at Annual Visit
Follow-Up Date
/
Month
/
Day
Year
Date
Please check everything completed during the appointment.
Unilateral Follow-Up, $250
Bilateral Follow-Up, $350
Datalogging
hours per day, right device
hours per day, left device
Comprehensive audiogram
Aided speech perception testing
Earmold impression(s)/fitting
Hearing aid real-ear verification and
*
I’ve included a copy of the audiogram from the follow-up
This is a first fitting and no audiogram is required
Audiogram Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
*
I certify that this child is at least 3 years old and has not yet graduated from high school.
Audiologist's Signature
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: