INVOICE FORM
APPLICANT'S 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
Note: Please fill out EITHER the initial or follow up section below, not both.
INITIAL FITTING
Complete ONLY at initial visit.
Fitting Date
/
Month
/
Day
Year
Date
Please select below:
Unilateral Fitting, $400
Bilateral Fitting, $600
Device( (s) Fit
FOLLOW-UP VISIT
Complete at ANNUAL visit. This visit must take place 365+ days after the last visit.
Initial Fit Date
-
Month
-
Day
Year
Date
Follow Up Date
/
Month
/
Day
Year
Date
Please check all that were completed during the appointment. Audiogram and
Unilateral Follow-Up, $250
Bilateral Follow-Up, $350
Comprehensive audiogram
Aided speech perception testing
Earmold impression(s)/fitting
Hearing aid real-ear verification and reprogramming as necessary.
Datalogging: How many hours per day was the RIGHT side worn?
Datalogging: How many hours per day was the LEFT side worn?
I've included a copy of the audiogram from the follow-up appointment.
Yes
File Upload: Please upload a copy of the audiogram from the follow-up.
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Audiologist's Signature
*
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
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