User Manual
Fill in the following information:
Mr. Mrs. Ms. Miss. Home Phone Number
First Name Last Name
Address
City State Zip
E-mail
Date of Purchase Date of Birth
Left Serial Number Device Style Simplicity Simply Soft
Right Serial Number
Waiver to Medical Evaluation Requirements:
is product is designed for adults and is not to be
worn by individuals under the age of 18. e Food and Drug Administration has determined
that it is in your best health interest to obtain a medical evaluation by a licensed physician, who
specializes in diseases of the ear, then to be tested by an audiologist, or hearing aid dispenser
utilizing established procedures and instrumentation in the tting of hearing instruments.
A prospective wearer may purchase hearing aids with out a medical exam by submitting a
medical waiver; however, FDA cautions that exercise of such a waiver is not in your best health
interest and use of waivers is discouraged. Purchasing this device over the counter constitutes
your acknowledgement and acceptance of the “Waiver to Medical Evaluation Requirements”.
My signature below constitutes acknowledgement and acceptance of this Waiver to Medical
Evaluation Requirements.
Signature: Date:
Regulations from the following states and districts have been reviewed: CA, CT, HI, ME, MA, NE, NJ, NM, NY, OH, OR, PA,
RI, TX, WA, WV, DC. All other states same as FDA guidelines.
GHI and authorized retailers have taken steps to ensure that their policies meet or exceed all state regulations.
1. 90 day in store money-back guarantee
2. Purchase by those under the age of eighteen (18) will not be permitted.
3. The medical waiver will never be promoted by either GHI or retailers. A signed waiver is required prior to purchase.
The signed waiver is maintained by GHI in excess of seven (7) years.
4. Minimum 30 day trial period after purchase. Extended trial may be oered and will vary from retailer to retailer
All personal information is considered condential and will not be shared with other companies.
PRODUCT REGISTRATION & MEDICAL WAIVER
Please fold and tape ends together. Do not staple.
Please complete registration with waiver and present to a pharmacy associate.
Device is not for sale without signed and complete waiver.
* Serial numbers are laser etched on each device
and printed on the bottom of the device carton.
Tear card at perforation Tear card at perforation
FORM MWRC-V001-0822516
Please have customer sign waiver printed below prior to sale of
device(s). Detach at perforation, tape ends together (do not staple)
and place card in designated area for U.S. Mail pickup.