Contact Us - Assitive Device

Required fields are indicated with an (*).

Name*

Email Address*

Address*

City*, State*, Zip*


Daytime Phone Number*

Evening Phone Number

ABOUT YOUR Device

My Device is called a:

Make

Model

This device assists me with:
Select One Hearing Sight Mobility My Motor Vehicle My Computer

Date of Purchase
Month Year

Device acquired :
New or Used

Was you device:
Leased or Purchased

Has you device been damaged by you while you have had it?
Yes or No

ABOUT YOUR PROBLEMS

About how many times has your device been in the repair shop for warranty work?

About how many calendar days has your device been out of service because of repair work?

In the spaces provided, please list each problem that your device has experienced, the number of trips to the repair shop for each, and whether you think it is fixed now.

Problem #1
Number of Repair Trips:
Fixed now?: Yes No Don't Know

Problem #2
Number of Repair Trips:
Fixed now?: Yes No Don't Know

Problem #3
Number of Repair Trips:
Fixed now?: Yes No Don't Know

Problem #4
Number of Repair Trips:
Fixed now?: Yes No Don't Know

Please provide any additional information you'd like to add.

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