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Clinic Name
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Clinic Email
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PO Reference:
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If not applicable, please write N/A
Client Name
*
If not applicable, please write N/A
Date of fitting
*
Day
/
Month
/
Year
Client type
*
DVA
HSP
Other
Audeara Device
*
Please Select
A-01 Headphones
A-02 Headphones
BT-01 Transciever
A-02 TV Bundle
Audeara Buds
Type of return
*
Return for replacement
Repair
Change of mind
Reason for return
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