New Client Intake & Order "*" indicates required fields Contact InformationName* First Last Date of Birth*Must be 16 years and older YYYY MM DD Email* 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 - Industrial EarplugsRangers - Shooting EarplugsRiders - Motorcycle EarplugsAqua Block - Swim EarplugsAqua Block Pro - Swim EarplugsEarphone TipsRadio Comm. EarpieceVCRM-1 Race MonitorsVCEP-1 Custom EarphonesVCEP-2XB Custom EarphonesVCEP-3 PRO Custom EarphonesVCEM-1 Custom IEMVCEM-2XB Custom IEMVCEM-3 PRO Custom IEMsingle of pair Single ear only (not a pair) Which Ear?* Right Ear Left Ear Material for IEMs Silicone Acrylic Add Detachable Neck Cord? Yes, I want a detachable neck cord Solid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter DR 5 Filter DR 10 Filter DR 15 Filter DR 20 Filter Our motorcycle earplugs do not come with a permanent neck cord option due to their shallow profile. (r)Neck Cord?* None Permanent Neck Cord Detachable Neck Cord Convertible Neck Cord paNeck Cord?* None Permanent Neck Cord Detachable Neck Cord Convertible Neck Cord rgaAcoustic Filter Strength* ER 9 Music Filter ER 15 Music Filter ER 25 Music Filter DM 10 Music Filter (mini) DM 15 Music Filter (mini) DM 25 Music Filter (mini) DR 10 Filter (mini) DR 20 Filter (mini) cSolid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter DIM 9 Impulse Filter DIM 12 Impulse Filter DIM 19 Impulse Filter rgSolid 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. (pa)Solid or Filtered?* Solid (No filter) Hocks Noise Braker® 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. (pa1)Solid or Filtered?* Solid (No filter) Hocks Noise Braker® 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. (rga1)Solid or Filtered?* Solid (No filter) Hocks Noise Braker® 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. (pa1)filter data See filter data Neck Cord?* None Permanent Neck Cord Detachable Neck Cord Convertible Neck Cord ?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 Style* Full-Shell Full-Shell Low Profile Half-Shell Half-Shell Low Profile Canal Skeleton rc*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. Solid Colour or Swirl?* Solid Colour Make with 2-Colour Swirl Colour* Same colour for both Different colours for left & right Choose Colour* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose LEFT Colour* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose RIGHT Colour* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose Swirl Colour 1* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose Swirl Colour 2* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dOption ✨ Add Glitter ⚡ Add Glow in the Dark Choose Colour* Black Red Blue Clear cChoose LEFT Colour Black Red Blue Clear cChoose RIGHT Colour Black Red Blue Clear cChoose Colour* Black Red Blue Clear Light Orange Light Lime pChoose LEFT Colour* Black Red Blue Clear Light Orange Light Lime pChoose RIGHT Colour* Black Red Blue Clear Light Orange Light Lime pChoose Colour* Black Red Blue Clear Light Orange Light Lime rgChoose LEFT Colour* Black Red Blue Clear Light Orange Light Lime rgChoose RIGHT Colour* Black Red Blue Clear Light Orange Light Lime rgChoose Colour* Black Red Blue Clear Light Orange Light Lime rdChoose LEFT Colour* Black Red Blue Clear Light Orange Light Lime rdChoose RIGHT Colour* Black Red Blue Clear Light Orange Light Lime rdChoose Colour* Red Blue Light Orange Light Lime abChoose LEFT Colour* Red Blue Light Orange Light Lime abChoose RIGHT Colour* Red Blue Light Orange Light Lime abChoose Colour* Red Blue Light Orange Light Lime abproChoose LEFT Colour* Red Blue Light Orange Light Lime abproChoose RIGHT Colour* Red Blue Light Orange Light Lime abproChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcetChoose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcetChoose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcetChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White rcChoose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White rcChoose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White rcChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcrmChoose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcrmChoose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcrmChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep1Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep1Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep1Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep2Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep2Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep2Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep3Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep3Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep3Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem1Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem1Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem1Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem2Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem2Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem2Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem3Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem3Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem37-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.🤩 One-Time Offer - Save 25% Off Second PairSPECIAL OFFER YES, I want to add a second pair for 25% off (applicable to products of same or lesser cost)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.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
