I have been advised by an Earlux Hearing Pro that the FDA has determined that my best health interest may be served if I had a medical evaluation by a licensed physician before purchasing a hearing aid. I do not wish a medical evaluation before purchasing a hearing aid. I understand not all hearing problems can be treated by hearing aids. Some hearing problems can and shoud be treated medically.
HIPAA Compliance Acknowledgement:
We are required by law to maintain the confidentiality of any health information that identifies you. Earlux is committed to protecting patient privacy and securing patient records. We will not provide patient data to third party marketers. We will provide you with a copy of our Privacy Practices concerning your protected health data upon your request.
The undersigned agrees to the terms, conditions, services, cancelaation provisions and price of the hearing instrument(s), accessories, HIPAA and product services described above.
NOTICE OF CANCELLATION DATE OF TRANSACTION____________
YOU MAY CANCEL THIS TRANSACTION, WITHOUT ANY PENALTY OR OBLIGATION, WITHIN THIRTY (30) DAYS UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER, AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE, OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE BUYERS EXPENSE AND RISK. IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE, OR ANY OTHER WRITTEN NOTICE, OR SEND NOTICE TO EARLUX, INC. AT 5513 W. 1100 N. SUITE #202 HIGHLAND, UT. 84003,NOT LATER THAN MIDNIGHT OF___________________.
I HEREBY CANCEL THIS TRANSACTION. DATED: ___________________.