REORDER FORM

Please Note: The Custom Protect Ear “Re-order Form” is only for customers that have current (within the last 5 years) ear mold-impressions on file with Custom Protect Ear.

Serial Number:
This is the best way of tracking your DB Blocker. Serial Numbers can be found on cards or tags

To ensure your order is processed in a timely fashion, please enter as much information as you can.


Note: All Fields with a * are mandatory.

Personal Information

Shipping Address
(If different from personal information)

Please enter your employer information if applicable:


What method of payment will you provide:


What colour would you like?


Is this the same as you have ordered before?

Please enter the best contact information we can reach you to obtain credit card information:

Please leave this field empty.