U-1ST HEARING CARE CLINIC 1012 Suite G Philadelphia Church Road ~ Dallas, NC 28034 Tel: 704-689-5576 ~ Fax: 704-922-5976
PURCHASE AGREEMENT
FITTED EXCLUSIVELY FOR: _____________________________________________ Date: _____ /_____ /_____ The undersigned acknowledges purchasing the supplies and services listed herein under the terms and conditions shown. 1 2
Model: Right
Side
Beige
Color
Left
@$
Both
Brown
ea.
$
New
Condition Used
Other
Reconditioned
- Package(s) of batteries
Included
- Year factory warranty\Loss & Damage
Included
Fitting Charge
$
Subtotal
$ Ck. #______
Payment with Order
Cash
$ $
C/C H/C
$ $
Total down payment
$
Balance due in full upon delivery
$
Signature:
__________________________________
Street:
__________________________________
City, State, Zip:
__________________________________
Phone Number:
__________________________________
MAKE: ___________________ Serial Number:
Agent: _________________________________
NC LICENSE NUMBER: ____________________
MODEL: ___________________
STYLE: ________________________
__________________________________ (L) ___________________________________ (R)
Date of Delivery: ________________________________ Received by: _______________________________
TERMS AND CONDITIONS DISCLOSURE OF PRIVATE HEALTHCARE INFORMATION (PHI) AND INDIVIDUAL IDENTIFIABLE INFORMATION (IIHI): I understand that my private (PHI) and (HHI) as pertains to this contract will be disclosed to the hearing aid manufacturer and other hearing health entities for the purpose of making hearing aids and/or ear molds. REFUND POLICY: Instruments may be returned for any reason during the 30 day period following delivery to purchaser. All returns for credit or refund are subject to a _____% restocking and dispensing fee. Cancellation of orders prior to delivery of hearing instruments is subject to a _____% dispensing fee. Refunds issued once credit has been received from the manufacturer, typically within 4 to 6 weeks from the date of return of the aid(s). DOOR TO DOOR SALES: You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.
*LOSS, STOLEN AND DAMAGE INSURANCE: Coverage is limited to one occurrence per aid with a $300.00 co-pay per aid. WARRANTY COVERAGE: Mechanical failure due to any manufacturer defect, and remolding for one fit for one year on custom molded aids. EXCLUSIONS: Damaged aids due to abuse or mishandling. THIS HEARING AID WILL NOT RESTORE NORMAL HEARING, NOR WILL IT PREVENT FURTHER HEARING LOSS. The Hearing Care Professional (HCP) has made available a copy of the user instructional manual to the buyer before purchase of a hearing instrument. A $50.00 fee will be charged for all returned checks plus any applicable bank charges. It is agreed that if, on default, an agent acts to effect collection, all reasonable collection fees, attorney fees, interest, costs and all other expenses will be paid by the undersigned purchasers.
Purchaser (Consumer) acknowledges having read and consented to this Purchase Agreement.