New Client Form – Vancouver Custom Ear Plugs

"*" indicates required fields

👤 Contact Information

Name*

Date of Birth*

Must be 16 years and older

Email*

Phone*

🚚 Shipping Address

*NO SHIPPING REQUIRED*

Shipping Address*

Street Address Address Line 2 City Province Postal Code

👂🏻 About Your Ears

Have you ever had ear surgery?*

Yes

Are you on any blood thinning medication?*

Yes

Do you have a history of ear infections?*

Yes

How long since your last ear infection?*

Less than a month

1-6 months

Over 6 Months

Not since I was a kid

📝 Your Order

Please Select Your Product*

Style (size)*

Canal

Half-Shell

Full-Shell

Style*

Full-Shell

Half-Shell

Canal

Style*

Skeleton

Canal

Full-Shell

Half-Shell

Acoustic Filter

Solid or Filtered?*

Riders do not come with a permanent neck cord option due to their shallow profile.

Solid or Filtered?*

Solid (No filter)

Hocks Noise Braker® Filter

DIM 9 Impulse Filter

DIM 12 Impulse Filter

Solid or Filtered?*

Solid (No filter)

Hocks Noise Braker® Filter

DR 10 Filter

DR 20 Filter

DI 25 Industrial Filter

DIM 9 Impulse Filter

DIM 12 Impulse Filter

Solid (Class A) – Maximum noise reduction. Filtered – suppresses noise to a safe hearing level, while allowing important, normal conversation to be heard. Higher numbers block more sound. (protectors)

filter data

See filter data

Add Detachable Neck Cord?

Yes, I want a detachable neck cord

Neck Cord?*

None

Permanent Neck Cord

Detachable Neck Cord

Neck Cord?*

None

Detachable Neck Cord

Convertible Neck Cord?*

Add a Convertible Neck Cord

With Hocks Noise Braker – Detachable cord plugged into the top socket to hear speech better through the acoustic filter while protecting your hearing from damaging noise. Plug the removable cord into the vent (bottom socket) to receive more sound reduction.

Cable Options*

20″ Short Permanent Braided

58″ Long Permanent Braided

50″ Permanent w/In-Line Mic

*Please note that Triple Driver Earphones come in clear silicone only due to the placement of the drivers during manufacturing. A layer of colour can be added on the faceplate portion only for an additional fee, if requested.

Colour Options

Same colour both

Different colour L & R

2 Colour swirl

Swirl Colour 1*

Swirl Colour 2*

Choose Colour*

LEFT EAR – Colour*

RIGHT EAR – Colour*

Optional Add-Ons

✨ Add Glitter

⚡ Add Glow in the Dark

Choose Colour*

LEFT EAR – Colour*

RIGHT EAR – Colour*

Swirl Colour 2*

Swirl Colour 1*

Choose Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Swirl Colour 1*

Swirl Colour 2*

Choose Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Swirl Colour 1*

Swirl Colour 2*

Choose Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Swirl Colour 1*

Swirl Colour 2*

Choose Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Swirl Colour 1*

Swirl Colour 2*

Choose Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Swirl Colour 1*

Swirl Colour 2*

Choose Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Swirl Colour 1*

Swirl Colour 2*

Choose Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Choose LEFT Colour*

Choose RIGHT Colour*

Choose Colour*

vcep1

Choose LEFT Colour*

vcep1

Choose RIGHT Colour*

vcep1

Choose Colour*

vcep2

Choose LEFT Colour*

vcep2

Choose RIGHT Colour*

vcep2

Choose Colour*

vcep3

Choose LEFT Colour*

vcep3

Choose RIGHT Colour*

vcep3

Choose Colour*

vcem1

Choose LEFT Colour*

vcem1

Choose RIGHT Colour*

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Choose Colour*

vcem2

Choose LEFT Colour*

vcem2

Choose RIGHT Colour*

vcem2

Choose Colour*

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Upgrade Case?

Premium Zipper Pouch (included)

Floatable Zipper Pouch

Any Special Requests?

No ship

Single Ear?

Single ear only (not a pair)

Which Ear?*

Right Ear

Left Ear

Choose LEFT Colour*

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Choose RIGHT Colour*

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7-Day RUSH Option

7-Day Rush is manufacturing time only (business days). Does not include shipping time. However, we try our best to deliver RUSH orders within 7 days.

Add 7-Day RUSH (Earplugs)

Add 7-Day RUSH (earphones)

Product Name

Save 15% on a Second Pair

If you would like to add additional earplugs, a 15% discount will be applied to subsequent pairs.

This offer expires 7 days from today and is applicable to products of same or lesser cost of the first order.

We offer a second pair at a discount because the negative mold can still be used and we can produce a second pair with less labour and materials.

After 7 days, the negative is melted and we keep the original ear impressions on file.

SPECIAL OFFER

YES, I want to add a second pair for 15% off

Details of Extra Pairs

ℹ What Happens Next

Turnaround time to shipping is 3-4 weeks. If you opted for a 7-Day Rush, they will ship in 7 business days

Shipping is via Canada Post. Once shipped, your earplugs should arrive at your mailbox within 1-3 days.

You’ll get an email with a tracking number from us as soon as they’re on the way.

💳 Ways To Pay

Your order will be processed manually by our office after this appointment – either today or tomorrow.

$25 Deposit Paid at Booking?

Yes

No – booked over phone

Deposit

Subtotal

Shipping

GST

Total

Payment Options*

Charge my card on file

Email bill with payment link

We’ll send you an email with a payment link for the above amount and a copy of your invoice.

As soon as the invoice is paid, we’ll begin production on your earplugs.