I have been advised that my best interests would be served if I had a medical examination by an otologist or otolaryngologist or any licensed physician before my purchase of a hearing aid.
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(Registrant's Name) has fully and clearly informed me of the value of such medical examination. After such explanation, I voluntarily sign this waiver. I choose not to seek a medical examination before the purchase of the hearing aid.
_________________________
(Signature of Registrant)
_________________________
(Address of Registrant)
_________________________
(Signature of Purchaser)
_________________________
(Date of Signature)
28 Pa. Code § 25.211
This section cited in 28 Pa. Code § 25.205 (relating to additional application requirements); 28 Pa. Code § 25.210 (relating to receipt to purchaser-purchaser protection); 28 Pa. Code § 25.213 (relating to consumer review); and 28 Pa. Code § 25.214 (relating to recordkeeping).