New Client Intake & Order "*" indicates required fields How Did You Book This Appointment?* Online (paid deposit) Over the phone (no deposit) Contact InformationName* First Last Date of Birth*Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Must be 16 years and olderEmail* Phone*Shipping InformationShipping Address* Street Address Address Line 2 City Province British ColumbiaAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code About Your EarsHave you ever had ear surgery?* Yes No Are you on any blood thinning medication?* Yes No Do you have a history of ear infections?* Yes No How long since your last ear infection?* Less than a month 1-6 months Over 6 Months Not since I was a kid Consent* I have been fully informed of each step of the ear impression procedure and the outcomes, benefits and risks associated with the process.About Your OrderPlease Select Your Product*IEM Ear ImpressionsDrifters Sleep EarplugsConcertos Musician EarplugsProtectors Work EarplugsRangers Shooting EarplugsRiders Motorcycle EarplugsSealers Surf / Swim EarplugsMusic Custom Earbud TipsPilot Custom Earbud TipsVCRM-1 Race MonitorsComms. Mold (single side)VCEP-1 Custom EarphonesVCEP-2XB Custom EarphonesVCEP-3 PRO Custom EarphonesVCEM-1 Custom IEMVCEM-2XB Custom IEMVCEM-3 PRO Custom IEMAll of our custom products are made with medical grade, skin-safe, high-strength siliconeMaterial for IEMs Silicone Acrylic Add Detachable Neck Cord? Yes, I want a detachable neck cord Solid or Filtered* Solid (Class A) Hocks Noise Braker® Filter Impulse Filter Solid or Filtered?* Solid (Class A) Hocks Noise Braker® Filter Impulse Filter 25 dB Acoustic Filter 15 dB Acoustic Filter 10 dB Acoustic Filter Our motorcycle earplugs do not come with a neck cord option due to their shallow profile.Solid or Filtered?* Solid (Class A) Filtered (Hocks Noise Braker®) Solid (Class A) - Maximum noise reduction. Filtered (Hocks Noise Braker®) - suppresses noise to a safe hearing level, while allowing important, normal conversation to be heard.Neck Cord?* None Permanent Neck Cord Detachable Neck Cord Convertible Neck Cord Neck Cord?* None Permanent Neck Cord Detachable Neck Cord Neck Cord?* None Permanent Neck Cord Detachable Neck Cord Convertible Neck Cord Neck Cord?* None Permanent Neck Cord Detachable Neck Cord Acoustic Filter Strength* 10 dB (lightest sound reduction) 15 dB 25 dB (most sound reduction) Which Ear Is This For?* Right Ear Left Ear Cable Options* 20" Short Permanent Braided 58" Long Permanent Braided 50" Permanent w/In-Line Mic Style* Full-Shell Full-Shell Low Profile Half-Shell Half-Shell Low Profile Canal Skeleton Same Colour For Both?* Same colour for both No, I want to mix it up! Choose Colour* Clear Orange Yellow Red Blue Turquoise Green Lime White Purple Pink Beige Brown Black Grey Choose Colour* Clear Orange Yellow Red Blue Turquoise Green Lime White Purple Pink Beige Brown Black Grey Choose LEFT Colour* Clear Orange Yellow Red Blue Turquoise Green Lime White Purple Pink Beige Brown Black Grey Choose RIGHT Colour* Clear Orange Yellow Red Blue Turquoise Green Lime White Purple Pink Beige Brown Black Grey Choose Colour* Red Light Blue Black Orange Green Pink Choose LEFT Colour* Red Light Blue Black Orange Green Pink Choose RIGHT Colour* Red Light Blue Black Orange Green Pink Choose Colour* Clear Red Blue Black Pink Green Orange Choose LEFT Colour* Clear Red Blue Black Pink Green Orange Choose RIGHT Colour* Clear-ish Red Blue Dark Black Pink Hunter Light Green Orange Choose Colour* Clear Red Light Blue Black Orange Green Choose LEFT Colour* Clear Red Light Blue Black Orange Green Choose RIGHT Colour* Clear Red Light Blue Black Orange Green Choose Colour* Clear Red Blue Dark Black Choose LEFT Colour* Clear Red Blue Dark Black Choose RIGHT Colour* Clear Red Blue Dark Black Any Special Requests?What Happens NextTurnaround time is 3-4 weeks. If you need them sooner, we offer a rush service (see below). Shipping is via Canada Post.Once shipped, your earplugs should arrive in 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.7-Day RUSH Add 7-Day RUSH (Earplugs) Add 7-Day RUSH (earphones) 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.Product NameWays To PayPayment Options* Charge my card on file Email bill with payment link Charge your card on file? I authorize Vancouver Custom Earplugs Ltd. to charge the above Total amount for this order to my credit card on file that was used for booking today's appointment. You will receive an email with your receipt as soon as payment goes through.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. Δ
