Certificate of Hearing Loss Order Form

Please complete the form below to submit a Certification of Hearing Loss/Order on behalf of your veteran/client.

Step 1 of 3

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Military Branch

Dates of Service

Message

Veterans can now self-certify their hearing loss in order to receive a captioned phone at no cost. Just fill out the form online.