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Medical Clearance form & see your Doctor or Medical Waiver
If you do not want a medical examination, Federal law allows for a
fully-informed adult to sign a "Medical Exam Waiver Statement" declining the medical
evaluation.
Medical Exam Waiver Statement
I have been advised by HearSource.com & any or all of their representatives, that the
Food and Drug Administration has determined that my best health
interest would be served if I had a medical evaluation by a licensed
physician ( preferably a physician who specializes in diseases of the
ear ) before purchasing a hearing aid.
I do not wish a medical
evaluation before purchasing a hearing aids. Waiver Signature ____________________________________ Date ______________ In addition to placing your order, by signing the above line,
you are also stating that you are age 18 years of age or older, you have read and
understand the required F.D.A. notice and have made an informed
decision to purchase hearing aids without being seen by a physician. Additionally, By purchasing hearing aids from HearSource.com you agree
that you are the person that will be the end user and wearer. You also
agree that the reason for purchasing hearing aids from HearSource.com
is for the purpose of personal use only and not for competitive
research, resale or any other reason.
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