Download the Certificate of Hearing Loss/Order Form
If you have a patient with hearing loss that would benefit from Hamilton® CapTel®, it’s never been easier to order a no-cost1 Hamilton CapTel Phone. If you have any questions, please call 877-455-4227 or send e-mail to firstname.lastname@example.org.
Or provide your patient with a pre-printed form. If you’d like to order pre-printed forms, please call 877-455-4227.
Complete the form in its entirety. This requires your patient’s information and signature, as well as the signature of a Physician, Audiologist or Hearing Related Professional verifying your patient has a qualified hearing loss.
Submit the signed Certificate of Hearing Loss/Order Form as directed. Delivery typically takes 1-3 weeks.
Complete the Online Certificate of Hearing Loss/Order Form