Please copy and paste this text by typing your name at the bottom, then fax or email it to us to fulfill the waiver requirement.
I have been advised by Endeavorxp.com 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 (preferable a physician who specializes in diseases of the ear) before purchasing a hearing aid to check for any of the following conditions.
1. Visible or congenital or traumatic deformity of the ear.
2. History of active drainage from the ear within the last 90 days.
3. History of sudden or rapidly progressive hearing loss within the last 90 days.
4. Active or chronic dizziness.
5. Unilateral hearing loss of sudden or recent onset within the previous 90 days.
6. Audiometric air-bone gap equal to or greater than 15 decibels at 500 Hz, 1000 Hz, or 2000 Hz.
7. Visible evidence of earwax (cerumen) or any foreign body in the ear canal.
8. Pain or discomfort in the ear.
I have read the above and I am over 18 years old.
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Your Email address: ___________________
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