RETURN FOR CREDIT FORM For faster service, please complete your return for credit request online at www.widexpro.com.
Account #: _______________ Company Name:_______________________ Ship To #: ____________________________________Date:___________ Address:_____________________________________________________ Address: _____________________________________________________ City: _____________________________ State:________ Zip:___________ City: _____________________________ State:________ Zip:___________ P.O. #:_______________________________________________________ Clinician Phone #:______________________________________________ Clinician Name:________________________________________________ Clinician Email:________________________________________________ Patient First Name:_____________________________________________ Patient Last Name:_____________________________________________
Right Serial #:_________________________________________________ Left Serial #:__________________________________________________ Model #:_____________________________________________________ Model #:_____________________________________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________ REMOTE/DEX accessory/TV PLAY Serial #:___________________________
PLEASE SELECT REASON FOR RETURN BELOW Quality Issue
Exchange
2.4 GHz Connectivity
Financial Decision
Will Not Program
iPhone®
Patient Illness/Death
Poor Fit
Pairing Issues
Stock Return
Feedback
App Connection Issues
Patient Changed Mind
Mechanical Failure
Streaming Issues
Return for Credit to Dispense Competitor Product
Android™
Will not stream Intermittent streaming
RETURN POLICY (for all models) Up to 90 days after invoice date . . . . . . . . . . . . . . . . . . . . . . . . . . . Full Credit No returns will be accepted after 90 days from invoice date.
mRIC R D, RIC 10, RIC 312 D, FUSION, FUSION2, and PASSION hearing instruments must be returned with earwire and receiver to receive full credit. Subject to fees if items are missing. See Price & Policy Guide for price information.
Additional Comments: ____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________
Submit to: Widex USA, Inc., 185 Commerce Drive, Hauppauge, NY 11788 Attn: Customer Care Fax: 718.482.1884 Email to: customerservice@widexusa.com Phone: 1.800.221.0188
EARWIRE RETURN / EXCHANGE FORM Please do not dispose of earwires and receivers. Complete the form below for a return or exchange.
Account #: _______________ Company Name:_______________________ Ship To #: ____________________________________Date:___________ Address:_____________________________________________________ Address: _____________________________________________________ City: _____________________________ State:________ Zip:___________ City: _____________________________ State:________ Zip:___________ P.O. #:_______________________________________________________ Clinician Phone #:______________________________________________ Clinician Name:________________________________________________ Clinician Email:________________________________________________ Patient First Name:_____________________________________________ Patient Last Name:_____________________________________________
Model
RETURN INFORMATION
Serial Number of Hearing Aid
Model
REPLACEMENT INFORMATION
Serial Number of Hearing Aid
Conventional Receiver
Earwire RIGHT
EASYWEAR (Receiver/Earwire Combination)
LEFT
RIGHT
S
LEFT
RIGHT
M
LEFT
RIGHT
P
LEFT
S M P v2 M v2 P HP SP Wired HP* Wired SP*
-2 -1 0 1 2 3 4 5
-2 -1 0 1 2 3 4 5
S0R S1R S2R S3R S4R
S0L S1L S2L S3L S4L
M0R M1R M2R M3R M4R
M0L M1L M2L M3L M4L
P0R P1R P2R P3R P4R
P0L P1L P2L P3L P4L
S M P v2 M v2 P HP SP Wired HP* Wired SP*
-2 -1 0 1 2 3 4 5
-2 -1 0 1 2 3 4 5
S0R S1R S2R S3R S4R
S0L S1L S2L S3L S4L
M0R M1R M2R M3R M4R
M0L M1L M2L M3L M4L
P0R P1R P2R P3R P4R
P0L P1L P2L P3L P4L
Conventional Receiver
Earwire RIGHT
EASYWEAR (Receiver/Earwire Combination)
LEFT
RIGHT
S
LEFT
RIGHT
M
LEFT
RIGHT
P
LEFT
HP SP Wired HP* Wired SP*
-2** -1** 0 1 2 3 4 5
-2** -1** 0 1 2 3 4 5
S0R S1R S2R S3R S4R
S0L S1L S2L S3L S4L
M0R M1R M2R M3R M4R
M0L M1L M2L M3L M4L
P0R P1R P2R P3R P4R
P0L P1L P2L P3L P4L
HP SP Wired HP* Wired SP*
-2** -1** 0 1 2 3 4 5
-2** -1** 0 1 2 3 4 5
S0R S1R S2R S3R S4R
S0L S1L S2L S3L S4L
M0R M1R M2R M3R M4R
M0L M1L M2L M3L M4L
P0R P1R P2R P3R P4R
P0L P1L P2L P3L P4L
*Wired HP and SP have earwires attached. Please select earwire length only. **Earwire sizes -1 and -2 not available for wired HP and SP receivers.
Additional Comments: ____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________
Submit to: Widex USA, Inc., 185 Commerce Drive, Hauppauge, NY 11788 Attn: Customer Care Fax: 718.482.1884 Email to: customerservice@widexusa.com Phone: 1.800.221.0188
DFM39/1120
_____________________________________________________________________________________________________________________________