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We’ve made it simple to complete a Certificate of Hearing Loss/Order Form

Choose the method that’s best for you. If you have any questions, please call 877-662-4144 or send e-mail to .

Complete The Online Form

Complete the Online Certificate of Hearing Loss/Order Form

By completing the form online, your patient will receive a Hamilton CapTel Phone as quickly as possible.

Download The Printable PDF

Download the Certificate of Hearing Loss/Order Form as a printable PDF

You can complete the order form on behalf of your patient or provide your patient with a pre-printed form for completion.

Download the Noah Module

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!

FCC Regulatory Notice

FCC regulations regarding Internet Protocol Captioned Telephone Service (IP CTS) change frequently. The most recent version of the Hamilton CapTel Hearing Healthcare Certificate of Hearing Loss/Order Form (revision date January 5, 2015) can be downloaded above.

Please contact Hamilton CapTel Customer Care with any questions you may have.

Hamilton CapTel Corporate Office
1006 12th Street
Aurora, NE 68818
Phone: 877-662-4144
E-mail:

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