Hamilton CapTel Order Form

We’ve made it simple to complete an Order Form for a captioned telephone. By completing the form online, your patient will receive a Hamilton CapTel phone as quickly as possible.

Other methods to complete the order form

Download the Certificate of Hamilton CapTel Order Form as a printable PDF

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.

Delivery typically takes 1-3 weeks.

Download the Hamilton CapTel Order Form

Install the HIMSA Noah® Module for your office patient management software

Integration of the Hamilton CapTel Certificate of Hearing Loss/Order Form into your Noah 4 Office Management Software is now available. With the HIMSA-certified module, see how easy it is to order a Hamilton CapTel Phone for your patients!

Download the Noah Module

Hamilton® CapTel®

Or switch your 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

NOTE: High-speed internet can be Wi-Fi or Ethernet cable
  
(Installation assistance provided over the phone, online, or on-site where available.)

Patient Information

Please enter a valid First Name
Please enter a valid Last Name
Please enter a valid Street Address
Please enter a valid City
Select Patient State
Please enter a valid ZIP Code
Please enter a valid Phone Number
  
Please enter a valid Email Address

Healthcare Professional Information

Please enter a valid First Name
Please enter a valid Last Name
Please enter a valid Title
Select your Occupation
Please enter a valid Business/Agency
Please enter a valid Street Address
Please enter a valid City
Select your State
Please enter a valid ZIP Code
Please enter a valid Phone Number

Order Certification

Please fill out or correct:
Submit Order on Behalf of Patient

Required field

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