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Hearing Loss & Solutions Information Request Form
Please read the following before proceeding:

Miracle-Ear^® can send you additional information on hearing loss and hearing solutions through the U.S. mail. This offer is limited to:

People over 25 years of age.

Residents of the United States, Canada, Mexico, and Puerto Rico.

Information cannot be sent unless you fill out the form completely. Please allow three weeks for delivery. Thank you for your interest in Miracle-Ear^®.

Name:
Gender:	Male Female
Street Address:

City:
State:
Zip:
Country:
Home Phone:
Email:
Who are you inquiring for?
Yourself Spouse Someone Else
If inquiring for yourself, what is your date of birth?

Are you currently wearing a hearing aid?
Yes No
If "yes" is it a Miracle-Ear^® hearing aid?
Yes No

I want to hear about future information from Miracle-Ear in the form of:
Regular Mail	Email	Telephone
Further Comments:

You can also request additional information by calling 1-888-283-9450.
Thank you!