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Hamilton CapTel Certificate of Hearing Loss/Order Form

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 877-662-4144 or send e-mail to .

  1. Step #1

    Or provide your patient with a pre-printed form. If you’d like to order pre-printed forms, please call 877-662-4144.
  2. Step #2

    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.
  3. Step #3

    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

For quicker processing, complete the form online!

Live Assistance is available during the following hours:

Monday – Friday:
8:30 AM to 12:30 AM Eastern

Saturday, Sunday:
11:00 AM to 6:30 PM Eastern