First Name Last name Mailing Address City Country United States State / Province Phone number Email Product NEXUS HD APP-CONTROLLED HEARING AID ReCharge! Plus HA-900 Behind the Ear Receiver in Canal (RIC) Bluetooth Hearing Aids (Both Ears) Recharge! Plus: Behind-the-Ear (BTE) Thin-Tube Bluetooth Hearing Aids (HA-802) ReCharge! Behind-the-Ear (BTE) Thin-Tube Hearing Aids (HA-302) HEARIQ 4 APP-CONTROLLED HEARING AID HEARIQ ITC APP-CONTROLLED HEARING AID Completely In Canal (CIC) Black Hearing Aid (HA-1800) Additional (Single) Hearing Aids Peace of Mind Plan Wireless Neckband TV Listener & Hearing Amplifier with Remote Microphone, Rechargeable (TV-01) Additional Charging Bases OPEN BOX SPECIAL: Wireless Neckband Hearing Amplifier with Bluetooth Streaming, Rechargeable (EZ-Hear) Hearing Aid Dehumidifier Earwax Removal Spray Earhook Kit & Earhook Domes Ear Domes Behind the Ear Sound Tubes Hearing Aid Cleaning Wipes Hearing Aid Cleaning Spray Comfort Gel Cream Lotion Cleaning Tool Carrying Case Hearing Assist Batteries 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