Offline Order Forms

1. Download the correct form below
   
   

   MOMENT

   • MOMENT RIC / BTE  and  CAMISHA CUSTOM SHELL Order Form
   
   
   • MOMENT Custom Order Form
   
   
   

   EVOKE

   • EVOKE Custom Order Form
   
   
   • EVOKE CIC, CIC-M, XP (ITE)
   
   
   

   UNIQUE

   • UNIQUE Custom Order Form
   
   
   • UNIQUE CIC, CIC-M, XP (ITE)
   
   
   

   EVOKE, UNIQUE and CAMISHA Custom Shell

   • EVOKE, UNIQUE RIC/BTE and CAMISHA Custom Shell Order Form
   
   
   

   SERVICE

   • Repair-Remake Form
   
   
   • Return for Credit & Earwire Return-Exchange Form
   
   
   • WIDEX Loss & Damage Claim Form
   
   
   • CA MEDI-CAL Order Form


2. Fill out the writable pdf form with the required information and print the document.
3. Submit the completed form by doing any of the following:
   1. Fax to 631-273-0639
   2. Mail to Widex USA, Inc., 185 Commerce Drive, Hauppauge, NY 11788 Attn: Customer Care