INVOICE FORM
APPLICANT INFORMATION
Applicant’s Name
DOB
Fitting Audiologist
PO #
BILLING INFORMATION
Make Check Payable to
Billing Office Address
Billing Contact
Phone Number
Email
example@example.com
INITIAL FITTING
Please complete at initial visit
Fitting Date
/
Month
/
Day
Year
Date
Unilateral Fitting, $400
Bilateral Fitting, $600
Device(s) Fit
FOLLOW UP
Complete at Annual Visit
Initial Fit Date
/
Month
/
Day
Year
Date
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
Audiogram Upload
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I certify that this child is at least 3 years old and has not yet graduated from high school.
Audiologist's Signature
Date
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