Hearing Aid Purchase & Fitting Agreement

# Hearing Aid Purchase & Fitting Agreement > **Important — not medical advice.** For use by a licensed provider; verify state scope-of-practice and informed-consent rules. **Date:** ___________ **Audiology Practice Name:** ___________ **Audiologist / Hearing Care Provider:** ___________ **License Number:** ___________ **Patient Name:** ___________ ("Patient") **Date of Birth:** ___________ --- ## 1. Audiological Evaluation Consent (a) The Patient consents to a comprehensive audiological evaluation, which may include pure-tone air and bone conduction testing, speech audiometry (speech recognition threshold and word recognition), tympanometry, acoustic reflex testing, otoacoustic emissions (OAEs), and any additional tests the audiologist deems appropriate. (b) Testing procedures are non-invasive and pose no meaningful risk. Headphones and insert earphones deliver tones at calibrated sound pressure levels within safe limits. (c) **Type of Evaluation:** ___________ **Chief Complaint / Reason for Visit:** ___________ --- ## 2. Medical Clearance (a) Federal regulations (21 C.F.R. § 801.421) recommend that first-time hearing aid candidates be examined by a physician to rule out medically treatable causes of hearing loss before fitting amplification. The audiologist will advise the Patient whether a medical evaluation is recommended based on the clinical findings. (b) **Medical Clearance Status:** ___________ **Waiver of Medical Evaluation (Adults Only):** I, the Patient, am an adult and choose to waive medical evaluation before being fitted with hearing aids. I understand this may not be in my best interest and that a physician examination could identify treatable conditions causing my hearing loss. ___________