Score Components Inc
PO Box 1283, Monticello, MN 55362
Scoreinc.org
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Contact information:
Date:
Name:
Phone:
Email Address:
Ship To:
Name
Address
City
State
Zip code
Hearing aid information
LEFT EAR
Style: Full Shell Half Shell Canal CIC
Mini-Canal BTE Body Aid Other
Make:______________________
Model:_____________________
Serial#:_______________________
RIGHT EAR
Style: Full Shell Half Shell Canal CIC
Mini-Canal BTE Body Aid Other
Make:_______________________
Model: _______________________
Serial#:_______________________
REASON FOR THE REPAIR
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[L ][R ] Dead
Other
Other
[L ][R ] Weak
[L ][R ] Cracked-BrokenShell/Recase
Payment Information: Check Money Order PayPal
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Total Amount Enclosed
(MN Residents add 7% sales tax
$______________
Make checks/money orders payable to:
Score Components
PO Box 1283
Monticello, MN 55362
(612) 817-8924
We charge a base $90.00 per aid for a standard service.
If the device is in an extreme condition, we’ll happily give you a call for an estimate.
We suggest you send your hearing aid in a sturdy box via an insured and traceable means such as USPS Priority Mail. Please allow one-two weeks for standard repair processing time. Please call if you must send by FedEx or UPS. They will not deliver to a PO box.