Complete the Online Certificate of Hearing Loss/Order Form

Hamilton^® CapTel^®

Or switch the phone to one of these other options

Hamilton^® CapTel^® 880i

Choose This Phone

Hamilton^® CapTel^® 840i

Choose This Phone

Hamilton^® CapTel^® 2400i

Choose This Phone

Hamilton^® CapTel^® 880i

Choose This Phone

Hamilton^® CapTel^® 2400i

Choose This Phone

Hamilton^® CapTel^® 840i

Choose This Phone

Hamilton CapTel captioned telephones are available to people with hearing loss at no cost.

Please complete the form below to submit a Certification of Hearing Loss/Order on behalf of your patient.

Additional Order Information

Yes, please provide my patient with information on free installation

Patient Information

First Name Please enter a valid First Name

Last Name Please enter a valid Last Name

Street Address Please check the Street Address

City Please enter a valid City

State Select Patient State

ZIP Code Please enter a valid ZIP Code

Phone Number Please enter a valid Phone Number

Secondary Phone Please enter a valid Phone Number

Other Phone Please enter a valid Phone Number

Email Address Please enter a valid Email Address

Alternative Contact Information

Alternative Contact First Name Please enter a valid First Name

Alternative Contact Last Name Please enter a valid Last Name

Alternative Contact Email Address Please enter a valid Email Address

Alternative Contact Phone Number Please enter a valid Phone Number

Healthcare Professional Information

First Name Please enter a valid First Name

Last Name Please enter a valid Last Name

Title Please enter a valid Title

Occupation Select your Occupation

Business/Agency Please enter a valid Business/Agency

Street Address Please check the Street Address

City Please enter a valid City

State Select your State

ZIP Code Please enter a valid ZIP Code

Phone Number Please enter a valid Phone Number

Email Address Please enter a valid Email Address

Order Certification

I certify that the applicant authorizes me to transmit this certification and the information contained herein to Hamilton CapTel.

I certify, under penalty of perjury, that: 1) this applicant has hearing loss that necessitates the use of Captioned Telephone Service; and 2) I understand that the service is provided by a live communications assistant and is funded through a federal program; and 3) I have not been offered or provided any direct or indirect incentive (financial or otherwise) tied to this consumer’s decision to use the service and I have not been referred to the applicant by a TRS provider or its affiliates; and 4) I don’t have a business (other than providing this form), family or social relationship with the TRS provider or its affiliates; and 5) no joint marketing arrangement exists between myself/my organization and Hamilton CapTel, and I have not made, nor do I have the opportunity to make, a profit on the sale of IP CTS equipment to consumers.

Submit Order on Behalf of Patient

Required field

Alternatively, you can download the form here as a PDF, then scan and email, or mail or fax it in (fax number and address are located on the form).

Feel free to contact Customer Care with any questions via email at info@HamiltonCapTel.com or by phone at (877) 455-4227.