New Client Intake & Options Name* First Last Date of Birth*Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Must be 16 years and olderEmail* Phone*Your Shipping InformationShipping Address* Street Address (Apartment, unit, suite, or floor #) City Province ProvinceAlbertaBritish 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 Not since I was a kid Informed 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 OrderWhat type of custom earplugs are you ordering?*Drifters - Sleep EarplugsProtectors - Industrial EarplugsConcertos - Musician EarplugsRiders - Motorcycle EarplugsFloaties - Swimming EarplugsCustom Pilot EarbudsIEM Ear ImpressionsSolid or Vented (filtered) Class A Solid Class B Filter Class C Filter Do you want a neck cord?* No Cord Permanent Cord Detachable Cord Convertible Neck Cord (s/filter) Acoustic Filter Strength* 9 dB (lightest protection) 15 dB (most popular) 25 dB (most protection) Solid Colour or 2-Colour Swirl* Solid Color 2-Colour Swirl Do you want both earplugs the same colour?* Yes, same colour for both No, I want to mix it up Choose Your Colour*Turn your phone sideways to best view colors Clear-ish White Pearl White Blue Red Purple Green Beige Black Grey Brown Silver Gold Neon Pink Neon Lime Neon Yellow Neon Orange Teal Mauve Choose LEFT Colour*Turn your phone sideways to best view colors Clear-ish White Pearl White Blue Red Purple Green Beige Black Grey Brown Silver Gold Neon Pink Neon Lime Neon Yellow Neon Orange Teal Mauve Choose RIGHT Colour*Turn your phone sideways to best view colors Clear-ish White Pearl White Blue Red Purple Green Beige Black Grey Brown Silver Gold Neon Pink Neon Lime Neon Yellow Neon Orange Teal Mauve Choose Swirl Colour #1*Turn your phone sideways to best view colors Clear-ish White Pearl White Blue Red Purple Green Beige Black Grey Brown Silver Gold Neon Pink Neon Lime Neon Yellow Neon Orange Teal Mauve Choose Swirl Colour #2*Turn your phone sideways to best view colors Clear-ish White Pearl White Blue Red Purple Green Beige Black Grey Brown Silver Gold Neon Pink Neon Lime Neon Yellow Neon Orange Teal Mauve Add-OnsAdditional Options 7 Days RUSH Order Glow in the Dark Metallic Glitter *Rushes are manufacturing time only (business days). Does not include shipping time.Special Requests(i.e. shipping instructions, colours, etc.) Δ
