First Name Last name Mailing Address City Country United States State / Province Phone number Email Product Additional (Single) Hearing Aids Additional Charging Bases Behind the Ear Thin Tubes Carrying Case Cleaning Tool Comfort Gel Cream Lotion CONNECT ITE Rechargeable OTC Hearing Aid Kit with Bluetooth Streaming & App Personalization CONTROL 2.0 RIC Rechargeable OTC Hearing Aid Kit with App Personalization CONTROL Classic RIC Rechargeable OTC Hearing Aid Kit with App Personalization Ear Domes Earhook Kit & Earhook Domes Earwax Removal Spray EAZE 2.0 RIC RECHARGEABLE OTC HEARING AID KIT Hearing Aid Batteries Hearing Aid Cleaning Spray Hearing Aid Cleaning Wipes Hearing Aid Dehumidifier with UV Sterilization MICRO Nearly Invisible CIC Peace of Mind Plan ReCharge! HA-302 BTE Thin-Tube Hearing Aids Recharge! Plus HA-802 BTE Thin-Tube Hearing Aids with App Personalization STREAM RIC Rechargeable OTC Hearing Aid Kit with Bluetooth Streaming & App Personalization Date of purchase Retailers Walmart Hearing Assist may occasionally send out information including but not limited to discounts, newsletters, and product advisories. To receive this information, please check one of the boxes below: Email Phone I prefer not to receive any communications from HearingAssist Register product