HearClear® Hearing Aid Battery | Free Sample

First Name:*

Last Name:*

Full Name Of Patient (if submitter is the guardian of the patient):

Your Email Address:*

Your Shipping Address:*

Name Of Your Cochlear Implant Manufacturer:*

Model Number Of Your Cochlear Implant:*

Year Cochlear Unit Implanted:*

Name Of Hospital/Clinic Cochlear Unit Was Implanted:*

Number of Implants:*

One ear implantedBoth ears implanted

Battery Type Currently Used:*
Please check all applicable battery types.
NiMH Rechargeable BatteryLi-Ion Or Li-Polymer Rechargeable BatteryPrimary Zinc Air Battery

If Primary Battery Currently Used, Indicate Brand & Model:*

Power One 675 Implant PlusRayovac 675 Cochlear PlusZenipower 675 Implant PowerAnother Brand

If another brand, please indicate zinc air battery brand below:

Where do you usually purchase your implant batteries?*

How did you learn about our website?*

Referral from a friend, family member, or aquaintance.Organic search results from a search engine.A paid advertisement box found on Google, Yahoo!, Bing,or another web page.

Do you want to join our mailing list?*

Sign Me Up!No Thank You!

Enter the code above:

This offer is available only once to qualifying consumers. Allow 2 to 6 weeks for your sample to arrive in the mail to you.