Voucher Exchange

Have you received your voucher?

Complete the form below to schedule an appointment.

Make sure the information on the voucher is correct.

Important:

DO NOT WRITE ON, MARK ON, SCRATCH OUT, OR USE PAPER LIQUID/CORRECTION TAPE (WHITE OUT)

Voucher Exchange Request

First name*

Name as it appears on the voucher.

Last name*

Name as it appears on the voucher.

Address*

Email*

Phone*

Voucher Number*

Voucher will NOT be processed prior to exchange.

Authorized Equipment*

*Device requires a landline.

Authorized Attachments (Choose all that apply)

Bluetooth Hub*

Headset, Neck Loop, or Cochlear Cord

Ring Signaler*

SGD Eye Control Access

Option SGD Head Pointing or Head Switch Device

SGD Key Guard

SGD Mount

SGD Switch

SGD Switch Mount

Voice Dialer*

Other

*Device may require a landline.

Need Help? Schedule a meeting with a consultant HERE

Contact
936-438-8445

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