Vancouver Custom EarplugsEar Impressions Consent Patient Intake FormΔ Updates First NameLast NamePhoneHave you ever had ear surgery? Yes NoAre you on blood thinning medication? Yes NoDo you have a history of ear infections? Yes NoHow long since your last ear infection? Less than 1 month 1 to 6 months Over 6 Months Not since I was a kidWhich product are you ordering?– Select Product –DriftersConcertosProtectorsRidersAquasafeRangersDensonicsDaily ReliefRadio CommVCEP Custom EarphonesVCEP Custom IEMSEarbud Tips/SleevesJust Ear Impressions (IEMs)How did you hear about us? Friend / Family Google Search Facebook / Instagram Clinic / Professional Referral OtherEar Anatomy Details (Optional) I have ear piercings or other ear features that may affect the fit of my earplugs.Left ear photoTake Picture – Left Ear Right ear photoTake Picture – Right Ear Submit Form