Hearing Aid Repair Lab

Established 1967
Phone: 707-462-8211
Toll Free: 800-653-8882
Fax: 707-462-4858
email: info@lillielectronics.com

168 Washington Ave
Ukiah CA 95482
website: www.lillielectronics.com

Hearing Aid Repair Form
and
Battery Order Form

Name                                                                                                                                        

Address                                                                                                                                     

City                                                                          State                   Zip                                  

Phone                                              Date                            Email                                               

Make                                                                           Serial#                                                    

Please indicate how you found us. [  ]Returning Customer:  [  ]Google:  [  ]Yahoo:  [  ]Popular Mechanics:

Friend (                                                                                )   Other (                                 )

Describe problem with hearing aid                                                                                

                                                                                                                                                 

Hearing aid batteries, 2 pack minimum. Each pack contains 4 batteries. 

QTY

Description

Unit Price

Sub Total

  Hearing Aid Repair     (Includes return shipping by "Priority Mail")

$162.00

 
  Batteries      Indicate size:________        (Free Shipping)

$3.00

 
   Shipping,  "Express Mail"   "2 day"             
    $18.00
 
   Shipping,  "FedEx"          "Next Day"  by 3 PM              
      $34.00
 
                                                Check or Money Order only   (Sorry, no credit cards)

Total Enclosed

$

Print this form. Complete it and include it with your hearing aid or battery order

Thank you !

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